Form I-693 - Report Of Medical Examination And Vaccination Record Page 3
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13Family Name (Last Name)
Given Name (First Name)
Middle Name
A-Number (if any)
A-
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Part 3. Interpreter's Contact Information, Certification, and Signature (continued)
Interpreter's Mailing Address
3.
Street Number and Name
Apt.
Ste.
Flr. Number
City or Town
State
ZIP Code
Province
Postal Code
Country
Interpreter's Contact Information
4.
Interpreter's Daytime Telephone Number
5.
Interpreter's Mobile Telephone Number (if any)
6.
Interpreter's Email Address (if any)
Interpreter's Certification
I certify, under penalty of perjury, that:
I am fluent in English and
, which is the same language specified in Part 2., Item B.
in Item Number 1., and I have read to this applicant in the identified language every question and instruction on this form and his or
her answer to every question. The applicant informed me that he or she understands every instruction, question, and answer on the
form, including the Applicant's Certification, and has verified the accuracy of every answer.
Interpreter's Signature
7.
Interpreter's Signature
Date of Signature
(mm/dd/yyyy)
Parts 4. - 9. of this form must be completed by the civil surgeon.
Part 4. Applicant's Identification Information (To be completed by the civil surgeon)
Please complete the following about the applicant:
1.
Form of identification presented by applicant (for example, passport or driver's license)
2.
Document Identification Number
Form I-693 10/19/17 N
Page 3 of 13
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