Mark A Ivener, A Law Corporation

Case Form

Petitioner Information

Company Name (if applicable)
Contact Person (if applicable)

Basic Contact Information

First Name
Middle Name:
Last Name
Other Names Used:
Home Phone
Work Phone
Fax
Email

Your Residence in the U.S.A. - Only if CURRENTLY in the USA

US Address 1:
US Address 2:
City/Town:
State:
Zip Code:

Biographical Details

Your Residence Outside of the U.S.A.

Address Abroad:
Address Line 2:
City/Town:
State/Province/Prefecture:
Postal Code:
Country:

Biographical Details

Sex:
Birthdate (YYYY-MM-DD):
Birthplace (City/Country):
Citizenship:
U.S. Social Security Number (if any, no dashes please):
USCIS A Number (if any):

Passport Questions

Do you currently have a valid passport?
 Yes  No
Country of Issuance:
Passport Number:
Expiration Date (YYYY-MM-DD):

Current Immigration Status

Are you currently in the USA OR Will you be in US at the time of Application?
 Yes  No
Date arrived (YYYY-MM-DD):
Current Visa Status:
I-94 Number:
I-94 Expiration Date (YYYY-MM-DD):

Immigration History & Admissibility

Have you ever been to the USA before?  Yes  No
If YES, please explain (visa, purpose, when, etc.).
Has your U.S. visa ever been cancelled or revoked?  Yes  No
If YES, please explain the details (when, why, etc.):
Have you ever been given or filed for this classification before?
 Yes  No
If YES, please explain the details (when, why, etc.):
Have you ever received a J-1 or J-2 visa?
 Yes  No
If YES, were you deemed to be subject to the two-year home country residency requirement of Section 212(e)?
 Yes No If you WERE deemed to be subject, have you received a waiver of Section 212(e)?
 Yes  No
Has anyone ever filed an immigrant visa petition on your behalf?
 Yes  No
If YES, please explain the details (when, why, final disposition, etc.):
Have you ever been arrested or convicted for any offense or crime, even though subject of a pardon, amnesty or other similar legal action? Have you ever unlawfully distributed or sold a controlled substance (drug), or been a prostitute or procurer for prostitutes?
 Yes  No
Have you ever been refused admission to the U.S. or been the subject of a deportation hearing, or sought to obtain or assist others to obtain a visa, entry into the U.S. or any other U.S. immigration benefit by fraud or willful misrepresentation or other unlawful means? Have you attended a U.S. public elementary school on student (F) status or a public secondary school after November 30, 1996, without reimbursing the school?
 Yes  No
Do you seek to enter the United States to engage in export control violations, subversion or terrorist activities, or any other unlawful purpose? Are you a member or representative of a terrorist organization as currently designated by the U.S. Secretary of State? Have you ever participated in persecutions directed by the Nazi government of Germany; or have you ever participated in genocide?
 Yes  No
Have you ever been employed without USCIS/INS authorization?
 Yes  No
Have you ever violated the terms of a U.S. visa, or been unlawfully present in, or deported from, the United States?
 Yes  No
Have you ever been arrested for Drunk Driving or any other alcohol related offense?
 Yes  No
Have you ever withheld custody of a U.S. citizen child outside the United States from a person granted legal custody by a U.S. court, voted in the United States in violation of any law or regulation, or renounced U.S. citizenship for the purpose of avoiding taxation?
 Yes  No
Have you ever been afflicted with a communicable disease of public health significance or a dangerous physical mental disorder, or ever been a drug abuser or addict?
 Yes  No
Do you have any specialized skills or training, including firearms, explosives, nuclear, biological or chemical experience?
 Yes  No
If you have further explanation you'd like to provide about the above questions, please explain here:

Family & Dependents

Marital Status:
How many dependents will be accompanying you?
Please complete the section on the right about your accompanying Dependents (Name, Birthdate, Birthplace, Citizenship, Current Residence)
Are any of the following related persons in the USA, or Do they have U.S. legal permanent residence (green card) or U.S. citizenship?
  In USA Green Card Citizen Other Status Residence
Husband/Wife
Father/Mother
Fiance/Fiancee
Son/Daughter
Brother/Sister

Consultation Request

Please explain your current immigration need.

Educational History

Please complete the chart below regarding your vocational, college, university education starting with the most recent.
Date Started (mm/yy) Date Ended (mm/yy) Diploma Degree? School Name School Location

Employment History & Experience

Please complete the chart below about your employment history starting with the most current. For each, please list the (1) Date Started and (2) Date Left (month and year), (3) your Job Title, (4) Hours per week worked, and (5) whether you can obtain a reference letter from this employer, if needed. Also, (6) briefly describe any special skills, tools, or equipment you used, the type of duties you performed.
Date Started
(mm/yy)		 Date Ended
(mm/yy)		 Job Title
Position		 Hours per Week Company Name Reference Letter Special Skills, Tools Equipment
OK
OK
OK
OK
OK

Acknowledgement

 You must acknowledge that you have read, understand and agree to this disclaimer to continue. Yes, I have prepared the answers to these questions to the best of my ability, and I believe them to be true and correct. I fully understand and accept the risks associated with submitting information via the Internet. I understand that if security is a concern to me, I have the option of printing this questionnaire and sending it to IVENER & FULLMER LLP via mail, courier or fax.
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