Immigration Intake Form
Name
First Name
Middle Name
Last Name
Date of birth
-
Month
-
Day
Year
Date
Home Phone Number
Please enter a valid phone number.
Business Phone Number
Please enter a valid phone number.
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
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
Please Select
Student
Visitor
Fiance
Temporary agricultural worker
Journalist
Victim of Criminal Activity
Religious worker
Father's Information
Name
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mother’s Information
Name
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Marital Information
What is your marital status
Single
Married
Divorced
Widowed
Date of Marriage
-
Month
-
Day
Year
Date
City and State/Nation of Marriage:
Spouse’s Name
First Name
Middle Name
Last Name
Spouse’s Birth Date
-
Month
-
Day
Year
Date
Spouse’s Nationality:
Spouse’s Social Security Number
Children Information
Name
First Name
Middle Name
Last Name
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
General Questions
Are you known by any other names? Include maiden or native alphabetic spelling.
Yes
No
Write other names you have used
Do you have a job or offer from a U.S. employer?
Yes
No
Employer's Name
Employer's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Description of the job you have been offered
Do you have family members now living in the U.S.?
Yes
No
Family Member Name
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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
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
Please give the reason and the relevant dates.
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.
Are you making a claim for political asylum?
Yes
No
Please provide the details, including the reasons for your claim.
Immigrant's Signature
Date
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: