PLEASE REVIEW THE FOLLOWING QUESTIONS BEFORE STARTING FILLING OUT THE FORM.

	PERSONAL DATA
	First Name:
	Middle Name:
	Last Name:
	Present Address:
	Phone Number:
	Email Address:
	Social Security Number:
	Place of Birth (City/Country):
	Date of Birth (Month/Date/Year):
	Country of Citizenship:
	Current Non Immigrant Visa:
	Expiration Date:
	Latest Date of Arrival at the U.S. Port:
	Permanent Address outside of the U.S. (Hometown Address):
	Address in the U.S. where you reside: (If different form present address)
	Dates and prior Periods of Stay in the U.S. for the past 6 Years:
	Arrival Date Departure Date Type of Visa 1. 2. 3. 4. 5. 6. 7. 8. 9.
	*Please review your answers before submitting.