Law Office of Ning Gan
1625 The Alameda, Suite 800
San Jose, CA 95126
Fax: 408 491 9760
Email:
Adjustment of Status Questionnaire for Employment Based Immigration
ATTNETION: PRINCIPAL APPLICANT AND EACH OF DEPENDENT APPLICANTS SHOULD COMPLETE THIS QUESTIONAIRE
Please enter your answers into the shaded column
PERSONAL INFORMATION REGARDING APPLICANTLast Name
First Name
Full Middle Name
Sex / Female____ Male______
Current Address
Cell Phone Number
Home Phone Number
Work phone number
Email address
Date of birth
City and Country of birth
Social security number (if any)
Country of Citizenship
Alien registration number (if any)
Date of Most Recent Arrival in the US
Place of Most recent entry into the U.S.(city/state)
Current nonimmigrant status
Expiration date of current nonimmigrant status
I-94#
Your mother’s first name
Your father’s first name
Consulate where visa was issue
Nonimmigrant visa number (the red number in the middle of your visa stamp, not the control number)
Date your visa was issued
Marital Status / Married ___ Single______Divorced______Widow______
Have you ever before applied for permanent resident status in the US / Yes ______No______
If yes, give date and place of filing and final disposition
List your present and past membership in or affiliation with every political organization, association, fund, foundation, party, club, society, or similar group in the United States or in any other place since your 16th Birth date. Include any foreign military service in this part. If none, write ”None”. Include the name of organization, location, dates of membership from and to, and the nature of the organization:
Family Member Information
SPOUSE
Last Name
First Name
Middle Initial
Date of birth:
Country of birth:
Relationship to you
Country of Citizenship
Apply with you / YES______NO______
CHILD
Last Name
First Name
Middle Initial
Date of birth:
Country of birth:
Relationship to you
Country of Citizenship
Apply with you / YES______NO______
CHILD
Last Name
First Name
Middle Initial
Date of birth:
Country of birth:
Relationship to you
Country of Citizenship
Apply with you / YES______NO______
CHILD
Last Name
First Name
Middle Initial
Date of birth:
Country of birth:
Relationship to you
Country of Citizenship
Apply with you / YES______NO______
CHILD# 4
Last Name
First Name
Middle Initial
Date of birth:
Country of birth:
Relationship to you
Country of Citizenship
Apply with you / YES______NO______
Passport number and expiration date:
INFORMATION FOR THE APPLICANT’S PARENTS
INFORMATION ABOUT Father
Last Name
First Name
Middle Name
Date of Birth
City & County of Birth
City and Country of Residence
INFORMATION ABOUT MOTHER
Maiden Name
First Name
Middle Name
Date of birth
City and Country of birth
City and Country of Residence
INFORMATION ABOUT THE APPLICANT”S MARRIAGE
Current Marriage
Name of Spouse
Date of Birth of Spouse
Place of Birth of Spouse
Date and place of marriage
Previous Marriage
Name of former Spouse
Date of birth of former Spouse
Place of Birth of former Spouse
Date and Place of Previous Marriage
Date and Place of termination of marriage
INFORMATION ABOUT THE APPLICANT”S RESIDENCE FOR THE PAST FIVE YEARS
Please list current address first
Street Address / City / State / From (mon/yr) / To (mon/yr)
INFORMATION ABOUT THE APPLICANT’S LAST RESIDENCE ABROAD
Street Address / City / State / From (mon/yr) / To (mon/yr)
INFORMATION ABOUT THE APPLICANT”S EMPLOYMENT FOR THE PAST FIVE YEARS
Please list current employment first
Name and address of employer / From (mon/yr) / To (mon/yr)
INFORMATION ABOUT THE APPLICANT’S LAST EMPLOYMENT OVERSEAS
Name and address of employer / From (mon/yr) / To (mon/yr)
Please answer the following questions. (If your answer is "YES" on any one of these questions, explain on a separate piece of paper.
a. Have you ever, in or outside the U.S.:
- knowingly committed any crime of moral turpitude or a drug-related offense for which you have not been arrested?
- been arrested, cited, charged, indicted, fined, or imprisoned for breaking or violating any law or ordinance, excluding traffic violations?
- been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency or similar action?
- exercised diplomatic immunity to avoid prosecution for a criminal offense in the U.S.?
___ Yes __ No
b. Have you received public assistance in the U.S. from any source, including the U.S. government or any state, county, city, or municipality (other than emergency medical treatment), or are you likely to receive public assistance in the future?
___ Yes __ No
c. Have you ever:
- within the past 10 years been a prostitute or procured anyone for prostitution, or intend to engage in such activities in the future?
- engaged in any unlawful commercialized vice, including, but not limited to, illegal gambling?
- knowingly encouraged, induced, assisted, abetted or aided any alien to try to enter the U.S. illegally?
- illicitly trafficked in any controlled substance, or knowingly assisted, abetted or colluded in the illicit trafficking of any controlled substance?
___ Yes __ No
d. Have you ever engaged in, conspired to engage in, or do you intend to engage in, or have you ever solicited membership or funds for, or have you through any means ever assisted or provided any type of material support to, any person or organization that has ever engaged or conspired to engage, in sabotage, kidnapping, political assassination, hijacking, or any other form of terrorist activity?
___ Yes __ No
e. Do you intend to engage in the U.S. in:
- espionage?
- any activity a purpose of which is opposition to, or the control or overthrow of, the Government of the U.S., by force, violence or other unlawful means?
- any activity to violate or evade any law prohibiting the export from the Untied States of goods, technology or sensitive information?
___ Yes __ No
f. Have you ever been a member of, or in any way affiliated with, the Communist Party or any other totalitarian party?
___ Yes __ No
g. Did you, during the period March 23, 1933 to May 8, 1945, in association with either the Nazi Government of Germany or any organization or government associated or allied with the Nazi Government of Germany, ever order, incite, assist or otherwise participate in the persecution of any person because of race, religion, nationality, ethnic origin, or political opinion?
___ Yes __ No
h. Have you ever engaged in genocide, or otherwise ordered, incited, assisted or otherwise participated in the killing of any person because of race, religion, nationality, ethnic origin, or political opinion?
___ Yes __ No
i. Have you ever been deported from the U.S., or removed from the U.S. at government expense, excluded within the past year, or are you now in exclusion or deportation proceedings?
___ Yes __ No
j. Are you under a final order of civil penalty of violating section 274C of the Immigration Act for use of fraudulent documents, or have you by fraud or willful misrepresentation of a material fact, ever sought to procure, or procured, a visa, other documentation, entry into the U.S., or any other immigration benefit?
___ Yes __ No
k. Have you ever left the U.S. to avoid being drafted into the U.S. Armed Forces?
___ Yes __ No
l. Have you ever been a J non-immigrant exchange visitor who was subject to the 2 year foreign residence requirement and not yet complied with that requirement or obtained a waiver?
___ Yes __ No
m. Are you now withholding custody of a U.S. Citizen child outside the U.S. from a person granted custody of the child?
___ Yes __ No
n. Do you plan to practice polygamy in the U.S.?
___ Yes __ No
Required Documents
1.A full copy of your passport
2. All previous I-20, IAP66, H1B, L1 approval notices etc.
3. Marriage Certificate
4. Divorce Decree (if applicable)
5. Birth Certificate
6. 8 passport photos. Please click here for photo requirements
7. Medical Examination Results (Form I-693). Please click here for list of authorized surgeons by the INS.
9. Employment Letter from Current Employer. We will prepare this letter on your behalf.
10.W-2 Forms for the past three years
11.Most recent paycheck stub.