Immigration Status Questionnaire
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1Immigration Status Questionnaire
Name: _________________________
Date: ___________________________
Date of Birth: ___________________
Place of Birth: ____________________
Citizenship: ___________________
Most recent admission to the United States:
Date: _________________________
Port of Entry: _____________________
Type of Visa of Immigration Status (circle one):
(a)
Lawful permanent resident (green card)
(g)
Tourist visa
(b)
Temporary or conditional permanent resident
(h)
Student visa
(c)
Refugee
(i)
Employment visa
(d)
Asylee
(j)
Undocumented
(e)
Asylum applicant
(k)
Other: ___________.
(f)
Business Visa
If admitted on a visa, indicate the expiration date: __________________.
Chronologically list all prior admissions and departures from the U.S.:
Admission date
Port of Entry
Visa/Status
Departure date
_____________
___________
__________
_____________
_____________
___________
__________
_____________
_____________
___________
__________
_____________
Arrests and convictions:
Date of arrest
Charge
Type and date of disposition
Sentence
____________ ______________ ________________________ ________________
____________ ______________ ________________________ ________________
____________ ______________ ________________________ ________________
List grandparents, parents, spouse, children or brothers and sisters who are lawful
permanent residents or U.S. citizens. Indicate date of naturalization if applicable:
Name
Date of Birth
Relationship
LPR or USC
Date/Natz.
_______________
___________
___________
___________ ___________
_______________
___________
___________
___________ ___________
_______________
___________
___________
___________ ___________
• Have you ever been arrested or detained by an Immigration Official, or have
you ever been ordered to appear before an Immigration Judge? Yes: _____
No: _____
• Have you ever been the victim of domestic violence or a victim/witness to
some other crime? Yes: _____ No: _____
• If you return to your home country, do you fear being persecuted on the
basis of race, religion, nationality, political opinion, or membership in a
social group? Yes: _____ No: _____
• Have you ever been the victim of torture, and/or, if you return to your home
country, do you fear being the victim of torture in the future? Yes: _____
No: _____
• If your answer is “yes” to any of the above four questions, please explain.
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