General Immigration Intake
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Personal and Biographic Information
First Name
First Name is required!
Middle Name
Last Name
Last Name is required!
Other Names Used
Age
Age is required!
Gender
Male
Female
Other
Unknown
Gender is required!
Marital Status
Annulled
Common-Law
Divorced
Engaged
Married
Separated
Single
Widowed
Marital Status is required!
Country of Birth
Country of Birth is required!
Country of Citizenship
Country of Citizenship is required!
Primary Spoken Language
Primary Spoken Language is required!
English Proficiency
Very Good
Good
Poor
None
English Proficiency is required!
What type of immigration assistance are you seeking from our organization?
U.S. Address and Contact Information
Street Address Line 1
Street Address Line 1 is required!
Street Address Line 2
Apt
City
City is required!
State
State is required!
Zip
Zip is required!
Home Phone
Home Phone required!
Cell Phone
E-mail
E-mail required!
Preferred Method of Contact
Home Phone
Cell Phone
E-Mail
Preferred Method of Contact required!
Education and Employment
Highest level of education
Graduated high school
Completed GED
College, grad school, law school, etc
In School now
None of the above
This Question is required!
Please provide a description of all diplomas, degrees, or education certificates obtained
If in school now, provide school name and field of study
Are you currently employed?
Yes
No
This Question is required!
If yes, provide employer name and occupation
Immigration Status
Current Immigration Status
This Question is required!
Date Current Status Expires
Entries to the U.S.
Date first entered the U.S.
This Question is required!
How did you entered the U.S.?
Visa or visa waiver
Entered without inspection
Entered with false documents
Other
This Question is required!
If other was entered above, provide more information about your first entry to the U.S.
Have you left the U.S. since the first time you entered?
Yes
No
This Question is required!
If yes, approximately how many times have you exited and reentered?
When did you last re-enter the U.S.?
Family Information
Do you have any immediate relatives who are either citizens or lawful permanent residents of the U.S.?
Yes
No
This Question is required!
If yes, please indicate the specific family relationship (mother, father, spouse, children, sister, etc), status (citizen or LPR), and current place of residence (city, state, country).
Have you or has anyone in your family ever submitted a application for an U.S. immigration benefit?
Yes
No
This Question is required!
If yes, please indicate the type of application filed and the result (approved, denied, pending)
Other Information
Have you ever been arrested or convicted of a crime anywhere in the world?
Yes
No
This Question is required!
This includes tickets, juvenile arrests, and even cases that were dismissed or expunged.
If yes, provide information concerning the arrest or conviction.
Have you ever been deported or gone before an immigration judge?
Yes
No
This Question is required!
Have you ever claimed to be a citizen of the United States or have you ever used another name for immigration purposes or for any other reason?
Yes
No
This Question is required!
Have you ever filed a required U.S. income tax return?
Yes
No
This Question is required!
Have you ever violated your immigration status, including working without employment authorization in the U.S.?
Yes
No
This Question is required!
Have you been the victim of a crime, or are you the spouse, parent or child of a crime victim?
Yes
No
This Question is required!
Is there any reason you might be afraid of returning to your country?
Yes
No
This Question is required!
If yes, provide details as to why you are afraid to return.
Have you or someone else in your family ever served in the U.S. military?
Yes
No
This Question is required!
If yes, please provide details concerning the military service.
Are there any other issues you feel are relevant in assessing your case which have not been raised elsewhere within this intake?
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