BORRAR

PERSONAL INFORMATION
First name Middle name Last name

Date of birth Age Gender Country of birth

Select

Country of citizenship 1 Country of citizenship 2 (Optional)

Current address
CITY STATE COUNTRY ZIP CODE

ADDRESS

Applicant contact details

The data entered here must correspond to the main applicant. No spouse or children. Avoid entering employment or educational contact information.

PERSONAL EMAIL PRIMARY PHONE

INFORMATION OF THE SPONSOR THAT IS APPLYING

Sponsor name Position Location

ACADEMIC INFORMATION
ACADEMIC PROGRAM YES NO NAME OF INSTITUTION YEAR OF GRADUATION

High School

Bachelor

Post Graduate

None

Address of the High School institution:

CITY STATE COUNTRY ZIP CODE

ADDRESS

ENGLISH LANGUAGE PROFICIENCY

Writing Select Listening Select

Reading Select Speaking Select

Have you ever been to the United States of America? YES NO

IF YES, WHAT IS
Have you ever had a social security number? YES NO THE NUMBER SSN?
WORK EXPERIENCE OF PAST 3 YEARS
COMPANY NAME START DATE END DATE CURRENT JOB DESCRIPTION

JOB 1

JOB 2

JOB 3

DEPENDENTS INFORMATION
Relative # 1
Degree of kinship First name Middle name Last name

Select
Gender Country of birth Country of Citizenship

MALE FEMALE

Date of birth Highest level of education

HIGH SCHOOL BACHELOR POST GRADUATE NONE

Relative # 2
Degree of kinship First name Middle name Last name

Select
Gender Country of birth Country of Citizenship

MALE FEMALE

Date of birth Highest level of education

HIGH SCHOOL BACHELOR POST GRADUATE NONE

Relative # 3
Degree of kinship First name Middle name Last name

Select
Gender Country of birth Country of Citizenship

MALE FEMALE

Date of birth Highest level of education

HIGH SCHOOL BACHELOR POST GRADUATE NONE

Relative # 4
Degree of kinship First name Middle name Last name

Select

Gender Country of birth Country of Citizenship

MALE FEMALE

Date of birth Highest level of education

HIGH SCHOOL BACHELOR POST GRADUATE NONE

Are you legally married? YES NO OTHER

If YES, date and country of marriage COUNTRY DATE OF

MARRIAGE

If OTHER, (divorced, widow, separated)

please CLARIFY:
EMERGENCY CONTACT INFORMATION
Name Phone number

Degree of kinship Address

Select

IMMIGRATION RECORDS

Please answer for the principal applicant and dependents

Applicant YES NO
Are you currently in the US?
Dependents YES NO

If yes, who:

If you are currently in the US, please provide your most recent I-94 number

Applicant YES NO
Do you currently hold a US Visa?
Dependents YES NO

If YES fill the table:

US VISA RECORD

NAME TYPE OF VISA EXPEDITION DATE EXPIRATION DATE

Applicant YES NO
Have you ever been rejected
for a visa?
Dependents YES NO

If YES fill the table:

US VISA REJECTION

NAME TYPE OF VISA REJECTION DATE REJECTION REASON

Have you ever overstayed your visa or I94?

Applicant YES NO Dependents YES NO If YES who

Have you ever been unlawfully present in the United States?

Applicant YES NO Dependents YES NO If YES who

Have you ever been denied entry to the United States?

Applicant YES NO Dependents YES NO If YES, please elaborate:

Have you ever been deported or told to leave from any country?

Applicant YES NO Dependents YES NO If YES, please elaborate:

Have you ever been before an immigration Judge/hearing officer?

Applicant YES NO Dependents YES NO If YES, please elaborate:

INADMISSIBILITIES
Medical Conditions for any members Significant medical procedures for any family members
NAME CONDITION NAME PROCEDURE DATE

Have you ever been diagnosed with a sexually transmitted disease?

Applicant YES NO If YES, please elaborate: Dependents YES NO

Have you ever been diagnosed with Tuberculosis?

Applicant YES NO Dependents YES NO if YES, please elaborate:

Do you have health insurance?

Applicant YES NO Dependents YES NO if YES, please elaborate:

Do you have any criminal record?

Applicant YES NO Dependents (14 years or above) YES NO

If YES fill the table:

NAME TYPE OF RECORD DATE OUTCOME

Have you ever been convicted of a crime?

Applicant YES NO Dependents YES NO If YES, please elaborate:

In the last year have you consumed any illegal substances?

Applicant YES NO Dependents YES NO If YES, please elaborate:

Do you have any substantial debt? Such as student loans, mortgage etc

Applicant YES NO Dependents YES NO If YES, please elaborate:

Disclosure

Signature