Form
Inspired Citizenship Azusa City Library
Citizenship Program Application
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Name/Nombre
First Name
Last Name
Phone Number/Numero de Telefono
Please enter a valid phone number.
Address/Domicilio
Street Address / Numero de Calle
Street Address Line 2
City / Ciudad
State / Estado
Zip Code / Codigo Postal
Email / Correo Electronico
example@example.com
Date of Birth / Fecha de nacimiento
-
Month
-
Day
Year
Date/ Fecha
Sex/ Sexo
Male/Masculino
Female/Femenino
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Have you applied for citizenship?/Haz aplicado para la ciudadanía?
Yes/Si
No/No
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Age/Edad:
16-19
20-29
30-39
40-49
50-59
60-69
70+
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How many years have you been in the U.S.?/Cuantos años tiene en los E.E.U.U.
Years as a U.S. Resident/Años de Residente
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Racial Background / Raza
Asian/Asiático
Black/Negro
Latino
Pacific Islander/ Isleño del Pacifico
White/ Blanco
Other
Education Completed/Educación
less than 3rd grade/menos de 3 años
4th - 9th grade / primaria
high school, no diploma / secundaria
high school diploma/GED
some college, no degree/ colegio
College or University graduate/ graduado/a de colegio o universidad
Master's Degree / posgrado
Employment/Empleo:
full time / tiempo completo
Part time / medio tiempo
Unemployed / desempleado
Retired / Retirado
On disability / En disabilidad
Other / Otro
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What country are you from? / De que país es usted?
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What languages do you speak?/¿Que idiomas habla?
Have you studied English? / Ha estudiando en Ingles?
Yes/Si
No
If yes, where? / Si la respuesta es si, donde?
If yes, how many years? / Si la respuesta es si, cuantos años?
Do you listen to English? /Comprende el Ingles?
Yes/ Si
No
Do you speak English? / Habla ingles?
Yes/Si
No
Do you read English? / Lee en ingles?
Yes/Si
No
Do you write English? / Escribe en ingles?
Yes/Si
No
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Do you have a library card?/ Tiene una tarjeta de la bíblioteca?
Yes/Si
No
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For scheduling purposes. Mark on the time slots where you work or have scheduling conflicts. / Por cuestion de horarios, por favor marque los tiempos de trabajo o donde tiene impedimentos para asistir
Monday/
Lunes
Tuesday/
Martes
Wednesday/
Miércoles
Thursday/
Jueves
Friday/
Viernes
Saturday/
Sabado
8-11 a.m.
11-2 p.m.
2-5 p.m.
5-8 p.m.
What language will your interview be in?/¿En que idioma va a ser su entrevista para la ciudadanía?
English/Ingles
Spanish/Español
Otro idioma
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How did you hear about the citizenship class?
family-friend/familiar-amigo/a
co-worker/compañero de trabajo
church or community/iglésia o comunidad
Other/Otro ___________________
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