Data Sheet To Be Completed By H-1b Beneficiary

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Data Sheet to be completed by H-1B Beneficiary
Name as it appears in your passport:
Family Name/Surname: _______________________________________________________________________________
Given Name: ____________________________________
Middle Name: ___________________________________
List all other names you have used in the past (such as your full maiden name). If none, so state.
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Your date of birth:
Month _______________
Day _______
Year____________
Country of your citizenship: _______________________
Country of your birth: ____________________________
The city of your birth: ____________________________
The province of your birth: _______________________
Your US Social Security Number (if any): ________________________________________________________________
Number issued to you by U S C I S (if any): _______________________________________________________________
This number is also called your Alien Registration Number. It would be reflected on an E A D issued for O P T.
NOTE: If you have been issued an E A D, provide a legible copy.
Your Passport Number: ___________________________
Date Passport Issued: _____________________________
Date Passport Expires: ____________________________
Country in which Passport was Issued _______________
NOTE: With this form, you must provide a legible copy of the identity page of your passport and the page which reflects its
expiration date, if that date is not on the identity page. Also provide a legible copy of all US visas issued to you and a copy of
each US admission stamp in your passport.
If you are currently inside the US, provide your current US home address.
If you are not currently inside the US, enter “none” __________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
As a non-immigrant statusholder in the US, you are required to maintain a permanent address in your home country.
What is your permanent address in your home country?
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
If you are currently outside the US, provide the US Consulate where you will apply for your visa.
US Consulate or Embassy in (city and country): ___________________________________________________________
If you are currently inside the US with dependents, do your dependents wish to file for either an extension or a change of
their current US immigration status? ______________________________________________________________________

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