I-693 Immigration Exam

Your Full Legal Name (Do not provide a nickname)

Given Name (First Name)Middle Name (if applicable)Family Name (Last Name)

In Care Of Name (if any)

Street Number and Name

ApartmentSuite NameFloor

Apartment, Suite , or Floor Number [if any]

City or Town

State

ZIP Code

Province

Postal Code

Country

Gender

MaleFemale

Date of Birth (mm/dd/yyyy)

Date

City/Town/Village of Birth

Country of Birth

Alien Registration Number (A-Number) (if any)

USCIS Online Account Number (if any)

Are you eligible for the vaccination record portion only and have already completed an overseas immigration exam?

I am eligible for completion of the vaccination record portion only, because I previously completed an overseas immigration medical examination, signed by a panel physician (refugee or derivative asylee adjustment of status applicants under Immigration and Nationality Act (INA) section 209 and K nonimmigrant visa holders applying for adjustment of status.

Applicant's Daytime Telephone Number

Applicant's Mobile Telephone Number (if any)

Applicant's Email Address (if any)

example@example.com

Interpreter's Name, if any

Interpreter's Given Name (First Name)1.Interpreter's Family Name (Last Name)

Interpreter's Business or Organization Name

Interpreter's Daytime Telephone Number

Interpreter's Mobile Telephone Number (if any)

Interpreter's Email Address (if any)

example@example.com

Person Preparing this Application, if Other Than the Applicant

Preparer's Given Name (First Name)Preparer's Family Name (Last Name)

Preparer's Business or Organization Name

Preparer's Daytime Telephone Number

Preparer's Mobile Telephone Number (if any)

Preparer's Email Address (if any)

example@example.com