Biographic data for U.S.

Citizen

1. NAME: _____________________________________________________________________
FIRST NAME MIDDLE LAST NAME

2. OTHER NAMES USED: _______________________________________________________

3. FULL NAME IN NATIVE ALPHABET (IF ROMAN LETTERS ARE NOT USED):
____________________________________________________________________________

4. DATE OF BIRTH: ____________________________________________________________

MONTH / DAY / YEAR HEIGHT / WEIGHT EYE COLOR / HAIR COLOR

5. PLACE OF BIRTH: ___________________________________________________________

CITY OR TOWN PROVINCE COUNTRY

6. NATIONALITY: ______________________________________________________________

7. GENDER (check one): ____ MALE ____FEMALE

8. MARITAL STATUS (check one): ____SINGLE ____MARRIED

____DIVORCED ____WIDOWED ____SEPARATED

9. HOW MANY TIMES HAVE YOU BEEN MARRIED (including present marriage): ________

10. CURRENT ADDRESS:

____________________________________________________________________________
NUMBER STREET CITY STATE ZIP CODE

____________________________________________________________________________
COUNTRY TELEPHONE NUMBER E-MAIL

11. PRESENT OCCUPATION: _____________________________________________________

12. NAME OF SPOUSE: __________________________________________________________

13. DATE & PLACE OF MARRIAGE: _______________________________________________

14. FATHER’S INFORMATION:

NAME: _______________________________________________________________
FIRST MIDDLE LAST

DATE OF BIRTH: ______________________________________________________

MONTH / DAY / YEAR

PLACE OF BIRTH: _____________________________________________________

CITY OR TOWN COUNTRY

CURRENT ADDRESS: __________________________________________________

CITY OR TOWN COUNTRY

IF DECEASED, GIVE YEAR OF DEATH: __________________________________

Biographic Data
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15. MOTHER’S INFORMATION:

NAME: _______________________________________________________________
FIRST MIDDLE LAST (MAIDEN NAME)

DATE OF BIRTH: ______________________________________________________

MONTH / DAY / YEAR

PLACE OF BIRTH: _____________________________________________________

CITY OR TOWN COUNTRY

CURRENT ADDRESS: __________________________________________________

CITY OR TOWN COUNTRY

IF DECEASED, GIVE YEAR OF DEATH: __________________________________

16. LIST THE PLACES YOU HAVE LIVED FOR THE LAST FIVE (5) YEARS:
STREET & NUMBER CITY OR TOWN PROVINCE COUNTRY FROM/TO
(month & year)
_______________________ _________________ _____________ ________________ ___________
_______________________ _________________ _____________ ________________ ___________
_______________________ _________________ _____________ ________________ ___________
_______________________ _________________ _____________ ________________ ___________
_______________________ _________________ _____________ ________________ ___________
_______________________ _________________ _____________ ________________ ___________
_______________________ _________________ _____________ ________________ ___________

17. LIST ALL EMPLOYMENT FOR THE LAST 5 YEARS:

EMPLOYER LOCATION JOB TITLE FROM/TO (month & year)
__________________________ ___________________ ___________________ _________________
__________________________ ___________________ ___________________ _________________
__________________________ ___________________ ___________________ _________________
__________________________ ___________________ ___________________ _________________
__________________________ ___________________ ___________________ _________________
__________________________ ___________________ ___________________ _________________
__________________________ ___________________ ___________________ _________________

18. SOCIAL SECURITY NUMBER: ____ ____ ____ - ____ ____ - ____ ____ ____ ____

19. HOW WAS YOUR CITIZENSHIP ACQUIRED (please check one):

______ Birth in the United States
______ Naturalization
______ Parents

I hereby acknowledge that the above is true and correct to the best of my knowledge.

_________________________________ ___________________________
SIGNATURE DATE