IMMIGRATION INTAKE FORM

Date: ____________________________

Last Name: _______________________________ First Name: __________________ MI ___

Street Address: _________________________________________________________________

City: ______________________ State: ______ Zip Code: _________

Home Phone: ____ - _____ - ________ Business Phone: ____ - _____ - ________

Cellular or Pager: ____ - _____ - ________ Email Address: ______________________

Date of Birth (month/day/year): _____ - ______ - ______

City and Nation of Birth: ________________________________________________________

Nationality: _____________________

Other Citizenship? (please circle) YES NO

If yes, specify: ________________________

Social Security Number: ______ - _____ - ________

A number (green card or work permit): _____________________________________________

I94 Number: ________________________________

Passport Number: _____________________________

Date Expires: ________________________ Date Issued: ____________________

Location Issued: ______________________________

Type of Non-Immigrant Visa (visitor, fiancé, student, etc.): _____________________________

Date of Last Entry to U. S. _________________ Place of Last Entry to U.S.: _______________

 Addresses during the Last 5 Years
Street City State & Zip Code Dates

Employment for the Last 5 Years

Company Phone # Dates
 Father’s Information

Father’s Name: _____________________________________ Birthdate: _______________

Location of birth, city, nation: ____________________________________________________

Present Address: _____________________________________________

_____________________________________________

Mother’s Information

Mother’s Name: ____________________________________ Birthdate: _______________

Location of birth, city, nation: ____________________________________________________

Present Address: _____________________________________________

_____________________________________________

Marital Information

What is your marital status (please circle)?

Single Married Divorced Separated Widowed

Date of marriage: ____________________________________

City and State/Nation of Marriage: _________________________________________________

Spouse’s name: _________________________________________

Spouse’s birth date: ______________________________________

Spouse’s City and Nation of Birth: __________________________

Spouse’s nationality: _____________________________________

Spouse’s Social Security Number: _____ - ______ - ______

Spouse’s Prior Spouse: ___________________________________

Date and place of Marriage: ______________________________

Date and place of Divorce: _______________________________

Spouse’s Prior Spouse: __________________________________

Date and place of Marriage: ______________________________

Date and place of Divorce: _______________________________

Spouse’s Addresses during the Last 5 Years

Street City State & Zip Code Dates

Spouse’s Employment for the Last 5 Years

Company Phone # Dates

Spouse’s Father’s Name: ____________________________ Birthdate: _______________

Location of birth, city, nation: ____________________________________________________

Present Address: ________________________________________

________________________________________

Spouse’s Mother’s Name: ____________________________ Birthdate: _______________

Location of birth, city, nation: ____________________________________________________

Present Address: ________________________________________

________________________________________

ALIEN’S PRIOR MARRIAGE INFORMATION

Name of prior spouse: ____________________________ Birthdate: _______________

Date and Place of Marriage: _______________________ ________________________

Date and Place of Divorce: ________________________ ________________________

SPOUSE’S PRIOR MARRIAGE INFORMATION

Name of prior spouse: ____________________________ Birthdate: _______________

Date and Place of Marriage: _______________________ ________________________

Date and Place of Divorce: ________________________ ________________________

 GENERAL QUESTIONS:
(CIRCLE ANSWERS, provide detail as specified)

Are you known by any other names? Include maiden or native alphabetic spelling. YES NO
If yes, list other names you have used:

___________________________________________

___________________________________________

Do you have a job or offer from a U.S. employer? YES NO

If yes, please provide the employer’s name and address, and a description of the job you have
been offered.

___________________________________________

___________________________________________

Do you have family members now living in the U.S.? YES NO

If yes, please provide the name and address of your family member, and describe how you are
related to that family member.

____________________________ ______________________________
______________________________

____________________________ ______________________________
______________________________

Please set out the reason(s) you wish to enter, or remain in, the U.S.
______________________________________________________________________________

______________________________________________________________________________

If you are applying for a visa to enter the U.S., do you wish to bring members of your family
with you? YES NO

Have you ever entered the U.S. on a visa other than a tourist visa? YES NO
If yes, please provide the dates you were in the U.S. and the type of visa used.

______________________________________________________________________________

Have you ever been denied permission to enter the U.S., or ordered to leave the U.S.? YES NO
If yes, please give the reason and the relevant dates.

______________________________________________________________________________
Have you ever been convicted of a crime (other than non-criminal traffic offense)? YES NO
If yes, please provide the details, including the offense for which you were convicted, the
sentence or penalty imposed, and the date of the offense.
______________________________________________________________________________

______________________________________________________________________________

If you are now in the U.S. have you been ordered to leave, or do you believe you may be ordered
to leave? YES NO
If yes, please provide the details, including the reason for the order.
______________________________________________________________________________

______________________________________________________________________________
Are you making a claim for political asylum? YES NO
If yes, please provide the details, including the reasons for your claim.

______________________________________________________________________________

______________________________________________________________________________
Have other attorneys worked on this matter? YES NO
If yes, provide names, addresses, and a brief description of their involvement:

______________________________________________________________________________

______________________________________________________________________________
 CHILDREN INFORMATION

First Child’s name: ______________________________ A# ____________________

Current Address: _________________________________ SS# ____________________
_________________________________
Date child entered United States: ____________________ DOB: __________________

Second Child’s name: _____________________________ A# ____________________

Current Address: _________________________________ SS# ____________________
_________________________________
Date child entered United States: ____________________ DOB: __________________

Third Child’s name: ______________________________ A# ____________________

Current Address: _________________________________ SS# ____________________
_________________________________
Date child entered United States: ____________________ DOB: __________________

Fourth Child’s name: _____________________________ A# ____________________

Current Address: _________________________________ SS# ____________________
_________________________________
Date child entered United States: ____________________ DOB: __________________

EMPLOYER INFORMATION (If employer petition)

Name of Business: _______________________________________________

Contact person: _________________________________________________

FEIN #: ___________________________ Type of Business: __________________________

Business Address: ________________________________________

________________________________________

Date business established: ____________________________________

Number of Employees: ______________

Nature of applicants work: ___________________________________

SOC Code: ______________ NAICS Code: ______________

Number of Employees beneficiary supervises: ____________________