Form I-924 - Application For Regional Center Designation Under The Immigrant Investor Program Page 4

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Other Names Used By the Principal Non-Owner of
Part 4. Information About the Organizational
the Regional Center Entity (if applicable)
Structure, Ownership, and Control of the
Regional Center Entity (continued)
Provide all other names the principal non-owner has ever used,
including aliases, maiden name, and nicknames.
Information About the Principal Non-Owner of the
26.a. Family Name
Regional Center Entity
(Last Name)
18.a. Family Name
26.b. Given Name
(Last Name)
(First Name)
18.b. Given Name
26.c. Middle Name
(First Name)
27.
Trade Name (DBA if any) (for the entity listed in Part 4.,
18.c. Middle Name
Item Number 23.)
19.
Date of Birth (mm/dd/yyyy)
20.
Country of Birth
Mailing Address For the Principal Non-Owners of
the Regional Center Entity
28.a. In Care Of Name (if any)
21.
U.S. Social Security Number (if any)
►
28.b.
Street Number and
22.
Position Held Within the Regional Center Entity
Name or PO Box
28.c.
Apt.
Ste.
Flr.
23.
Entity Name (for a principal of the Regional Center Entity
that is an entity or organization)
28.d. City or Town
28.e. State
28.f. ZIP Code
Federal Employer Identification Number (for a principal
24.
of the Regional Center Entity that is an entity or
28.g.
Province
organization)
28.h.
Postal Code
25.a. Persons Having Ownership, Control, or Beneficial
28.i. Country
Interest in the Entity Listed in Part 4., Item Number 23.
Contact Information For the Principal
25.b. Date of Birth (mm/dd/yyyy)
Non-Owners of the Regional Center Entity
25.c. Country of Birth
29.
Daytime Telephone Number
25.d. Percentage Ownership in the Entity Listed in Part 4.,
30.
Fax Number
Item Number 23.
%
25.e. Position Held (if any) in the Entity Listed in Part 4., Item
31.
Email Address (if any)
Number 23.
32.
Website Address (if any)
Form I-924 12/23/16 N
Page 4 of 11

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