US General Questionnaire

PRINCIPAL APPLICANT

Name:*

First & Middle NameLast Name

Other Surnames used: (Maiden, Religious, Professional, Aliases)

Other First and Middle Names used:

Sex:*

MaleFelmale

Date of Birth:*

Date

Place of Birth: (City/Province/Country)*

Country of Citizenship:*

Your native language:*

Mailing address: (Include city & country)*

Your residential address, if different from your mailing address:

Phone Number:*

Area CodePhone Number

Alternate Phone Number:

Area CodePhone Number

Email:*

example@example.com

Social Security Number (SSN) if applicable:

Employer Identification Number (EIN) if applicable:

When do you intent to arrive in the US?*

Date

BACKGROUND/DECLARATION

Do you belong to a clan or tribe?*

YesNo

Do you have any specialized skills or training, including firearms, explosives, biological or chemical experience?*

YesNo

Have you ever served in, been a member of, or been involved with paramilitary unit, vigilante unit, rebel group, guerrilla group or insurgent organization?*

YesNo

Do you have a communicable disease of public health significance such as tuberculosis (TB)?*

YesNo

Do you have a mental or physical disorder that poses or is likely to pose a threat to the safety or welfare of yourself or others?*

YesNo

Are you or have you ever been a drug abuser or addict?*

YesNo

Have you ever been arrested or convicted for any offense or crime, even though subject of a pardon, amnesty or other similar legal action? Have you ever unlawfully distributed or sold a controlled substance (drug), or been a prostitute or procurer for prostitutes?*

YesNo

Have you ever been refused admission to the U.S., or been the subject of a deportation hearing or sought to obtain or assist others to obtain a visa, entry into the U.S., or any other U.S. immigration benefit by fraud or willful misrepresentation or other unlawful means? Have you attended a U.S. public elementary school on student (F) status or a public secondary school after November 30 1996 without reimbursing the school?*

YesNo

Do you seek to enter the U.S. to engage in export control violations, subversive or terrorist activities, or any other unlawful purpose? Are you a member or representative of a terrorist organization as currently designated by the U.S. Secretary of State? Have you ever participated in persecutions directed by the Nazi government of Germany; or have you ever participated in genocide?*

YesNo

Have you ever violated the terms of a U.S. visa, or been unlawfully present in, or deported from the U.S.?*

YesNo

Have you ever withheld custody of a U.S. citizen child outside the U.S. from a person granted legal custody by a U.S. court, voted in the U.S. in violation of any law or regulation, or renounced U.S. citizenship for the purpose of avoiding taxation?*

YesNo

Have you ever been afflicted with a communicable disease of public health significance or a dangerous physical or mental disorder, or ever been a drug abuser or addict?*

YesNo

Are you coming to the United States to engage in prostitution or unlawful commercialized vice or have you been engaged in prostitution or procuring prostitutes within the past 10 years?*

YesNo

Have you ever been involved in, or do you seek to engage in, money laundering?*

YesNo

Do you seek to engage in espionage, sabotage, export control violations, or ay other illegal activity while in the United States?*

YesNo

Have you ever or do you intend to provide financial assistance or other support to terrorists or terrorist organizations?*

YesNo

Have you ever ordered, incited, committed, assisted, or otherwise participated in torture?*

YesNo

Have you committed, ordered, incited, assisted, or otherwise participated in extrajudicial killings, political killings, or other acts of violence?*

YesNo

Have you while serving as a government official, been responsible for or directly carried out, at any time, particularly severe violations of religious freedom?*

YesNo

Have you failed to attend a hearing on removability or inadmissibility within the last 5 years?*

YesNo

If your answer to any of these questions is YES, provide details below:

Education

Indication number of years of school successfully completed:

Elementary/Primary School*

Secondary/High school*

University/College*

Trade school or other post secondary school*

Details of all secondary and post secondary education (including university, college and apprenticeship training) you have had:*

	From (MM/YY)	To (MM/YY)	Name of Institution (include address + phone number)	City and country	Type of certificate or degree issued
Institution (1)
Institution (2)
Institution (3)

Membership or association with organizations

What organizations have you supported, been a member of or been associated with? Include any political, social, youth or student organization, trade unions and professional associations. Do not use abbreviations. Indicate the city and country where you were a member.

	From (MM/YY)	To (MM/YY)	Name of organization	Type of organization	Activities or positions held within organization	City and country
Organization (1)
Organization (2)
Organization (3)

Government positions

List any government positions (such as civil servant, judge, police officer) you have held. Do not use abbreviations.

	From (MM/YY)	To (MM/YY)	Country and level of jurisdiction e.g. national, regional, municipal	Department/Branch	Activities and positions held
Position (1)
Position (2)
Position (3)

Military service

Provide below details of military service for each of the countries in whose armed forces you served.

	Country	From (MM/YY)	To (MM/YY)	Branch of service, unit numbers and names of your commanding officers	Rank(s)	Dates and places of any active combat
Service (1)
Service (2)

WORK EXPERIENCE

List ALL your occupations since you left high school. Start with the current Canadian employment:

*List all positions you had. Each position should go on separate line*

	From (MM/YY)	To (MM/YY)	Position	Employer name and complete address *if the business doesn't exist any more, write city, province	Job duties
Job (1)
Job (2)
Job (3)
Job (4)
Job (5)

US ASSIGNMENT

Details of the position offered/assignment in the US:

Position/Title:

Duration:

Location:

Hourly/Monthly/Yearly Wage or Salary Rate:

Other benefits:

Job duties:

Name and title of the person you will be reporting to:

Name of person in the US being replaced:

Are you currently working in the US under a work permit?*

YesNo

TRAVEL HISTORY

Have you been issued any US visas before?

	Please provide type of visa, validity period and place of issuance
Visa (1)
Visa (2)
Visa (3)

Periods of stay in the US in that visa (provide the duration in terms of month, year):

Please note that the completion of this questionnarie is NOT an application for a US work visa. Its purpose is to obtain information to assist us in determining your suitability for a US work visa.

I declare that the information I have given in this application is truthful, complete and correct.

Date* at the city of blanks* in the province of blank* .

Signature of principal applicant:*

DOCUMENT CHECKLIST

1. Birth Certificate;
2. Passport;
3. Resume;
4. Certificate(s), Degree(s), Transcripts and/or Diploma(s);
5. Confirmation of previous employment including dates of employment and position(s) including letters of employment, record of employment (ROE), T4, T4A, T5; and
6. Rental Agreement or Land Title from country of citizenship or residence.

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