To Be Completed by the Beneficiary Employee for Whom the Status Or Extension of Stay Is

personal Information questionnaire

To be completed by the beneficiary employee for whom the status or extension of stay is sought.

Please provide all the information requested below. Should you have any questions regarding the information requested feel free to contact Assistant General Counsel Jigisha Patel at (617) 373-7073. Please return the completed personal information questionnaire along with your documents to your department/college administrator for processing. The Employee is responsible for completing all ‘Employee’ forms and providing the relevant supporting documents. Answer all questions, even if the answer if ‘N/A’ or ‘None’. Incomplete questionnaires will delay the Office of the General Counsel’s ability to complete the University’s petition in a timely manner.

Signature: ______Date Completed:

INFORMATION ABOUT BENEFICIARY EMPLOYEE

1) Your FULL legal name: First Middle Last

Any other names by which you have been known or used:

2)Your place of birth: Town/City: Province:

Country:

3)Country of Citizenship:

If naturalized, date of Naturalization:

4) Your date of birth: Month: Day: Year:

5) Current Primary Contact Information (either in the U.S. or abroad if not living in U.S.):

Phone number: E-mail address:

Address:

6)Permanent Foreign Contact Information:

Phone number:

Address:

Is this address also to be used as your mailing address while outside of the U.S.: _____Yes____No

7)Current immigration status: F-1/OPT_____ TN_____ H-1B_____ J-1/2_____ O-1_____

Other:

None: Not in the U.S., or will be processing outside of the U.S., or will not be in the U.S. at the time of filing

IF YOU ARE NOT IN THE U.S., Location of Consulate or Port of Entry where you will apply for your visa:

City Country

8)Date that status expires:

*Note: If you are currently in H-1B status, please include the last 4 months of your payroll records and you will be asked to provide updated payroll records until the H-1B petition is filed.

9)Have you ever held J visa status? ______yes ______no

If “yes”, were you subject to the two year return to home country provision? ______yes ______no

If “yes”, have you secured a waiver or served the two years in your home country? ____ yes ____no

10) Additional information needed of U.S. immigration history:

a) If you have ever held F or J visa status, list the dates and your SEVIS number(s):

b) If you have ever applied for or been granted an Employment Authorization Document (EAD), list your receipt number(s) beginning with three letters and provide copies of your EAD cards:

11)Social Security Number (if applicable):

12) USCIS or “A Number” (if applicable):

13)Date and place of last entry/arrival into the U.S.:

Date:

Place:

14)Passport number: Date issued:

15)Expiration date of current passport:

16)Most recent I-94 Admission Record Number:

17)Name and address of current employer:

18)Date you plan to end employment with that company:

*Note: If you are currently holding H-1B status, please do not end your employment without speaking with Jigisha Patel at the Office of the General Counsel, 617-373-7073.

19)Have you or has anyone else filed a petition or application for permanent residency on your behalf?

______yes______no

20) Has any nonimmigrant or immigrant petition filed on your behalf ever been denied?

______yes ______no If yes, please provide details and receipt number:

21)Please list below any upcoming travel and notify the Office of the General Counsel of any changes to travel plans after completing this questionnaire and while this petition is pending. This is important as traveling outside of the U.S. while your petition is pending may result in the petition being deemed abandoned.

YOUR EDUCATION HISTORY IN THE UNITED STATES AND ABROAD:

Name & Address of School: (most recent first)

Dates of Study: From To Visa Status held if in U.S.:

Name & Address of School: (most recent first)

Dates of Study: From To Visa Status held if in U.S.:

Name & Address of School: (most recent first)

Dates of Study: From To Visa Status held if in U.S.:

YOUR EMPLOYMENT HISTORY IN THE UNITED STATES AND ABROAD:

Name and Address of Employer: (current or most recent first)

Official Title of Position Held:

Beginning date (mm/dd/yyyy): End date (mm/dd/yyyy):

Visa Status Held if in the U.S.:

Name and Address of Employer: (current or most recent first)

Official Title of Position Held:

Beginning date (mm/dd/yyyy): End date (mm/dd/yyyy):

Visa Status Held if in the U.S.:

Name and Address of Employer: (current or most recent first)

Official Title of Position Held:

Beginning date (mm/dd/yyyy): End date (mm/dd/yyyy):

Visa Status Held if in the U.S.:

Name and Address of Employer: (current or most recent first)

Official Title of Position Held:

Beginning date (mm/dd/yyyy): End date (mm/dd/yyyy):

Visa Status Held if in the U.S.:

DOCUMENT CHECKLIST FOR BENEFICIARY EMPLOYEE

PLEASE PROVIDE THE FOLLOWING DOCUMENTS:

For yourself:_____copy of passport ID page and all stamped pages from your current passport

_____copy of your most recent I-94 Admission Number Record

_____ copies of any and all prior immigration status documents (for example: SEVIS Forms I-20 for F student status; SEVIS Forms DS-2019 for J status; Form I-797 approval notices for H-1B, O-1, etc.

_____ copies of any current or expired Employment Authorization Documents (EAD cards)

_____if currently in H-1B status, provide copies of past 4 months of payroll records from current employer, and provide updated payroll records until the H-1B petition is filed

_____ if currently working in the U.S. in a visa status outside of Northeastern, please provide an employment verification letter after speaking with Jigisha Patel in the Office of the General Counsel

_____ copies of all degree certificates/diplomas AND transcripts from the Bachelor’s level to the highest degree awarded with English translations if necessary.

_____current resume or curriculum vitae listing all employment

DEPENDENT FAMILY MEMBERS

Is your spouse’s or child’s immigration status dependent upon yours? ______yes______no ______N/A

If your spouse and/or children are in the U.S. and their status is dependent on your status, your dependent(s) will need to complete and submit an I-539 Application to Extend/Change Nonimmigrant Status in the U.S. The Form I-539 with instructions and additional information is available at www.uscis.gov. The immigration form must be accompanied by a check in the amount of $290 made payable to “U.S. Department of Homeland Security.” If you would like your personal Form I-539 application packet to be mailed together with the University’s employment-based nonimmigrant petition filing, please timely send the completed Form I-539 packet to the Office of the General Counsel. If you choose to file separately on your own, please let us know and we will provide you with a copy of the University’s petition filing receipt notice once available.

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Revised April 2014