QUESTIONNAIRE FOR H-1B OR L-1 VISA:

Last name: / First name: / Middle:
List all other names used:
Home Address:
Home telephone #: / Home fax #:
Office Address, including M/S#:
Office telephone #: / Office fax #:
Title of your position:
H. R. Contact:
H.R. Telephone #
& e-mail:
Date of Birth: / Place of Birth:
(mo/day/yr) (City, State, Country)
Social Security #: / Nationality:
A# (if any): / Male/Female:
Current Non-immigrant status: / Expires on:
Have you ever before applied for permanent residence status? If so, give date and place of filing
and final disposition:
1. / Information about your father:
Last name
First name
Date, city and country of birth
City and country of residence
2. / Information about your mother:
Maiden name
First name
Date, city and country of birth
City and country of residence
3. / Your residence for the last five years. List present address first.
Street and Number / City / State / Country / From
(mo./yr) / To
(mo./yr)
4. / Last residence outside the U.S. for more than one year.
Street and Number / City / State / Country / From
(mo./yr) / To
(mo./yr)
5. / Employment for the last five years. List present employment first.
Name of Employer, Street and Number / City / State / Country / Occupation / From
(mo./yr) / To
(mo./yr)
6. / Last occupation abroad if not shown above.
Name of Employer, Street and Number / City / State / Country / Occupation / From
(mo./yr) / To
(mo./yr)
7. / Date of last arrival:
8. / No. on I-94 card:
9. / Place of last entry in the U.S.:
10. / City and country where visa was issued:

11. 8 Digit Non-immigrant visa #: ______

Date Visa was issued: ______

Visa Expiration Date: ______

12. / Have you ever been in the U.S. on a visa?
If yes, please list the dates (day-month-year) you were in U.S.:
13. / Have you ever before applied for employment authorization from INS?
If yes, which INS office?
Date(s) of application:
Granted or denied?
Please provide copies, front and back, of your work authorization card.
14. / Information about your spouse:
Last name (for wife, give maiden name)
First name
Date and place of marriage
Applying with you?
Current Status?
15. / Your former husbands or wives (if none, so state)
Last name (for wife, give maiden name)
First name
Date of birth
City and country of birth
Date and place of marriage
Date and place of termination of marriage
16. / List all of your children: / Child #1 / Child #2 / Child #3
Last name
First name
Middle name
Male or Female?
Date of birth
Place of birth
Country of Citizenship
A# (if any)
Social Security # or T.I.N.:
Applying with you?
17. / List your present or past membership in or affiliation with every political association, fund foundation, party, club, society, or similar group in the United States or in any other place since your 16th birthday. Include any military service in the past. If none, write “none.” Include the name of the organization, location, dates of membership from and to, and the nature of the organization. If additional space is needed, use separate paper.

COMPLETE ONLY IF THERE IS THE POSSIBILITY OF INTERNATIONAL TRAVEL OVER THE NEXT SIX MONTHS.

22. / Date of intended departure:
23. / Expected length of trip:
24. / Purpose of trip:

THE FOLLOWING QUESTIONS WILL APPEAR ON THE VISA APPLICATION. PLEASE CHECK YES OR NO.

1. / Have you ever been issued a U.S. visa? If yes, when, where, and type: ______/ Yes / No
2. / Has your visa ever been refused a U.S visa? If yes, when, where and type: ______/ Yes / No
3. / Names and Relationships of Persons Traveling with you: ______
4. / Has your U.S. visa ever been cancelled or revoked? / Yes / No
5. / Has anyone ever filed an Immigrant Petition (Form I-140 employment or Form I-130 relative) on your behalf? / Yes / No
6. / Are any of the following persons in the US in the US or have US permanent residency or citizenship status:
a) Husband/wife? / Yes / No
b) Fiancée/Fiancé? / Yes / No
c) Father/Mother? / Yes / No
d) Brother/Sister?
e) Son/Daughter? / Yes
Yes / No
No
7. / 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
8. / 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
9. / Do you seek to enter the U.S. to engage in export control violations, subversive 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
10. / Have you ever violated the terms of a U.S. visa or been unlawfully present in, or deported from the United States? / Yes / No
11. / Have you ever withheld custody of a U.S. citizen child outside the U.S. from a person granted legal custody by a U.S. court, voted in the U.S. in violation of any law or regulation, or renounced U.S. citizenship for the purpose of avoiding taxation? / Yes / No
12. / Have you ever been afflicted with a communicable disease of public health significance or a dangerous physical or mental disorder, or ever been a drug abuser or addict? / Yes / No
13. / Have you ever been a J nonimmigrant 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

If you would like further information about specific case scenarios or situations, please call our office or email us at to speak to one of experienced immigration attorneys.

DISCLAIMER: The confidential information provided in this memorandum is for information purposes only and is not intended to be legal advice. This information is not intended to create an attorney-client or other relationship between Kuck Immigration Partners LLC and the recipient. The reader should consult with an immigration attorney before acting in reliance on any such information.

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