Alien Registration Number (A-Number) (if any)
USCIS Online Account Number (if any)
U.S. Social Security Number (if any)
City/Town/Village of Birth *
State or Province of Birth *
Country of Birth *
Country of Citizenship or Nationality *
Country of Last Foreign Residence *
Mailing Address: In Care of
Country *
Name of Employer/Company 1 *
Your Occupation:
Name of Employer/Company 2
Your Occupation:
Relationship
Country of Birth
Relationship
Country of Birth
Relationship
Country of Birth
Relationship
Country of Birth
Relationship
Country of Birth
Place of Arrival or Port-of-Entry: City or Town
Place of Arrival or Port-of-Entry: State
Form I-94 Arrival-Departure Record Number
Date Period of Authorized Stay Expired, or Will Expire:
Passport Number
Travel Document Number
Country of Issuance for Passport or Travel Document
Current Nonimmigrant Status (if applicable)
Regional Center Name *
Regional Center Identification Number *
What is the receipt number for the approved Regional Center Application upon which your petition is based? *
If applicable, provide the New Commercial Enterprise (NCE) Identification Number
Total Amount Deposited or Committed to Deposit into U.S. Business Accounts for New Commercial Enterprise (NCE)
Total Value of Assets Purchased for Use in NCE
Total Value of All Property Transferred from Abroad for Use in NCE
Total of All Debt Financing
Total Stock or Other Equity Purchases
Other Capital
Your Gross Income at the Time of Investment
Your Net Income at the Time of Investment
Your Current Gross Income
Your Current Net Income
Your Net Worth at the Time of Investment
Your Current Net Worth
In the space below, describe the documentation included with this petition to demonstrate that the capital you have invested or are actively in the process of investing was obtained through lawful means:
Name of NCE *
Telephone Number of NCE
Type of Entity (for example, corporation, limited liability company, partnership)
Nature of Activity (for example, furniture manufacturer)
Included Industries (provide North American Industry Classification System (NAICS) Codes)
Explain how the NCE qualifies as a troubled business: *
Federal Employer Identification Number
Amount of Your Initial Investment in the NCE
Your Total Capital Investment in the NCE to Date
What percentage (%) of the NCE do you own?
Name of Party
Percentage of Ownership
Name of Party
Percentage of Ownership
Name of Party
Percentage of Ownership
Name of JCE
Telephone Number for JCE
Type of Entity (for example, corporation, limited liability company, partnership)
Nature of Activity (for example, furniture manufacturer)
Included Industries (provide North American Industry Classification System (NAICS) Codes)
Name of Additional Job-Creating-Entity *
Telephone Number for Additional JCE
Type of Entity (for example, corporation, limited liability company, partnership)
Nature of Activity (for example, furniture manufacturer)
Included Industries (provide North American Industry Classification System (NAICS) Codes)
What is your position, office, or title with NCE?
What are your duties, activities, and responsibilities in the NCE?
What is your current salary in the NCE?
What are your costs for benefits you receive in your current position in the NCE?
Number of Full-Time Direct and Qualifying Employees in the NCE at the time of your Initial Investment:
Current Number of Full-Time Direct and Qualifying Employees in the NCE:
Difference in Number of Full-Time Direct and Qualifying Employees:
Estimated Number of Full-Time Direct and Qualifying Employees that Will Be Created During the Relevant Time Period
Indicate the economic model used to estimate indirect job creation: *
Total amount of your capital that has been or will be made available to the JCE
Total amount of capital derived from investors who have not sought and are not seeking classification as alien investors:
Country of Citizenship or Nationality *
Country of Current Residence *
Country of Last Permanent Residence Abroad *
Telephone Number
City or Town, and State *
Please provide an explanation below: *
What is the language in which you are fluent? *
Preparer Business or Organization Name (if any)
Preparer's Daytime Phone Number *
Preparer's Mobile Phone Number
Preparer's Email Address *
Interpreter Business or Organization Name (if any)
Interpreter's Daytime Phone Number *
Interpreter's Mobile Phone Number
Interpreter's Email Address
I, the interpreter, certify under penalty of perjury, that I am fluent in English and: (Must be same language that you interpreted for the Petitioner)
Authorized Signatory's Title
Authorized Signatory's Daytime Phone Number
Authorized Signatory's Mobile Phone Number
Authorized Signatory's Email *