Information Pertaining to the Applicant

Please respond to every box:

 If unknown – write “unknown”
 If not applicable – write “N/A”
 If none – write “none”

Family History

Full Name (First, Middle Last)

US Social Security Number
Any other names used(please include
names by previous marriages)

Father's Full Name

Father's Date of Birth

Father's City and Country of Birth

Father's City and Country of

Residence

Mother's Full Name

Mother's Maiden Name

Mother's Date of Birth

Mother's City and Country of Birth

Mother's City and Country of

Residence

Marriage History

Full name of any former Date of Birth Date and Place of Marriage Date and Place of Termination
Husband or Wife (if none of Marriage
so state). Please include
maiden names if any.
Residence History
Please provide all addresses that you have held in the last five (5) years starting with your current
address. Please make sure there are no gaps.

Street Name and Number City State or Province Country Dates of Residency
(mm/dd/yyyy –
mm/dd/yyyy)

Please provide your most recent foreign address of more than one (1) year
Street Name and Number City State or Province Country Dates of Residency
(mm/dd/yyyy –
mm/dd/yyyy)

Please list all employment for the last five (5) years. If none, so state.

Employer Name Job Title City State or Country Dates of

Province Employment
(mm/dd/yyyy –
mm/dd/yyyy)
Please list your Last Occupation Abroad

Employer Name Job Title City State or Country Dates of

Province Employment
(mm/dd/yyyy –
mm/dd/yyyy)

Please Answer The Following Questions:

Have you EVER had any problem entering the U.S., obtaining a U.S. visa, or ANY contact with the
police in any country?

Have you ever been under immigration proceedings?

If you have children, even adult children, please provide a list of their names, dates of birth, and
countries of birth.

What is your current address abroad, if any?