Name
First Name
Middle Name
Last Name
Client Intake Form
Are you known by any other names? Include maiden or native alphabetic spelling.
Yes
No
Write other names you have used
Date of birth
-
Month
-
Day
Year
Date
Home Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Business Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Nation of Birth
Nationality
Other Nationality?
Yes
No
Please Specify other Nationality
Alien Number
Social Security Number
Passport Number
Passport Date Expires
-
Month
-
Day
Year
Date
Passport Date Issued
-
Month
-
Day
Year
Date
Location Issued
Type of Non-immigrant Visa on Entry
Please Select
Student
Visitor
Fiance
Temporary agricultural worker
Journalist
Victim of Criminal Activity
Religious worker
Date of Entry
-
Month
-
Day
Year
Date
Father's Information
Name
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Nation of Birth
Mother’s Information
Name
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Nation of Birth
Address History [Past Five Years, Most Recent First]
Address #2 [Immediately Prior to Current]
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date Moved In
-
Month
-
Day
Year
Date
Date Moved Out
-
Month
-
Day
Year
Date
Address #3, if applicable
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date Moved In
-
Month
-
Day
Year
Date
Date Moved Out
-
Month
-
Day
Year
Date
Address #4, if applicable
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date Moved In
-
Month
-
Day
Year
Date
Date Moved Out
-
Month
-
Day
Year
Date
Marital Information
What is your marital status
Single
Married
Divorced
Widowed
Spouse’s Name
First Name
Middle Name
Last Name
Date of Marriage
-
Month
-
Day
Year
Date
City and State/Nation of Marriage:
Spouse’s Birth Date
-
Month
-
Day
Year
Date
Spouse's Nationality
Spouse’s Social Security Number
Prior Spouse’s Name, if Applicable
First Name
Middle Name
Last Name
Prior Spouse’s Birth Date
-
Month
-
Day
Year
Date
Prior Spouse's Nationality
Prior Spouse Date of Marriage
-
Month
-
Day
Year
Date
Prior Spouse Date of Divorce
-
Month
-
Day
Year
Date
Children Information
Child #1 Name
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
City, State and Country of Birth
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child #2 Name
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
City, State and Country of Birth
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child #3 Name
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
City, State and Country of Birth
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer's Name [Most Recent Employer first, for past five years]
Employer(s) Information
Employer's Name [Current Employer]
Employer's Address [Current Employer]
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Start Date
-
Month
-
Day
Year
Date
End Date
-
Month
-
Day
Year
Date
Employer's Name [2nd Recent Employer, for past five years]
Employer's Address [2nd Most Recent Employer, past five years]
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Start Date
-
Month
-
Day
Year
Date
End Date
-
Month
-
Day
Year
Date
Employer's Name [Third Recent Employer, for past five years]
Employer's Address [Third Recent Employer, for past five years]
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Start Date
-
Month
-
Day
Year
Date
End Date
-
Month
-
Day
Year
Date
Have you ever entered the U.S. on a visa other than a tourist visa?
Yes
No
Please provide the dates you were in the U.S., and the type of visa used.
Have you ever been convicted of a crime (other than non-criminal traffic offense)?
Yes
No
Please provide the details, including the offense for which you were convicted, the sentence or penalty imposed, and the date of the offense.
Please provide additional information for any of the Fields Above, as needed
Immigrant's Signature
Date
-
Month
-
Day
Year
Date
File Upload Passport Biographic Page - Self
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File Upload Passport Biographic Page - Spouse
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File Upload Birth Certificate - with translation - for Self
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File Upload Birth Certificate - with translation - for Spouse
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File Upload - SELF - Driver's License and SSN Card
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File Upload - SPOUSE - Driver's License and SSN Card
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File Upload Divorce Decree(s), if Applicable - for Self
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File Upload Divorce Decree(s), if Applicable - for Spouse
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Marriage Certificate with Spouse
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Joint Utilities with Spouse
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Joint Bank Accounts with Spouse
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Joint Auto; Life or Health Insurance with Spouse
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Submit
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