Alien Registration Number (A-Number)
Explain other *
Country of Birth *
Country of Citizenship or Nationality *
USCIS Online Account Number (if any)
U.S. Social Security Number (if any)
Accommodation Request: *
Describe the nature of your disabilities and/or impairments and your accommodation request: *
Daytime Phone Number
Evening Phone Number
Work Phone Number
Mobile Phone Number
Email Address
Mailing Address: In Care of Name (if any) *
Mother's Country of Birth *
Mother's A-Number (if any)
Father's Country of Birth *
Father's A-Number (if any)
List below all the trips of 24 hours or longer that you have taken outside the United States during the last 5 years. Start with your most recent trip and work backwards. FOR EACH TRIP, PROVIDE: The dates you left the U.S. and the dates you returned. Did the trip last more than 6 months? Which Countries did you travel? Total days outside the United States.
How many times have you been married? (including annulled marriages and marriages to the same person)
Current Spouse's Current Employer or Company
Place of Marriage to Current Spouse - City or Town, State or Province, and Country
Current Spouse's Place of Birth - City or Town, State or Province, and Country *
A-Number (if any)
Explain Other:
Explain Other *
Country of Birth of My Current Spouse's Prior Spouse
Country of Citizenship or Nationality of My Current Spouse's Prior Spouse
Explain Other *
Explain Other *
Prior Spouse Country of Birth
Prior Spouse Country of Citizenship or Nationality
Explain Other *
Name of Employer or School Name 1 *
Your Occupation:
Name of Employer or School Name 2
Your Occupation:
Name of Employer or School Name 3
Your Occupation:
Height (in feet and inches) *
Weight (in pounds) *
A-Number (if any)
Country of Birth
Child's Relationship To You (for example, biological child, stepchild, legally adopted child)
A-Number (if any)
Country of Birth
Child's Relationship To You (for example, biological child, stepchild, legally adopted child)
A-Number (if any)
Country of Birth
Child's Relationship To You (for example, biological child, stepchild, legally adopted child)
A-Number (if any)
Country of Birth
Child's Relationship To You (for example, biological child, stepchild, legally adopted child)
A-Number (if any)
Country of Birth
Child's Relationship To You (for example, biological child, stepchild, legally adopted child)
Name of Organization 1 *
Purpose of the Group for Organization 1 *
Name of Organization 2
Purpose of the Group for Organization 2
Name of Organization 3
Purpose of the Group for Organization 3
Purpose of the Group for Organization 4
Provide an explanation that includes why you were not arrested, cited, detained, or charged; when the event occurred (date); the outcome or disposition (for example no charges filed, charges dismissed, jail, probation, community service) *
Provide an explanation that includes why you were arrested, cited, detained, or charged; where you were arrested, cited, detained, or charged; when the event occurred (date); the outcome or disposition (for example no charges filed, charges dismissed, jail, probation, community service) *
Provide an explanation that includes why you were arrested, cited, detained, or charged; where you were arrested, cited, detained, or charged; when the event occurred (date); the outcome or disposition (for example no charges filed, charges dismissed, jail, probation, community service) *
Provide an explanation that includes why you were arrested, cited, detained, or charged; where you were arrested, cited, detained, or charged; when the event occurred (date); the outcome or disposition (for example no charges filed, charges dismissed, jail, probation, community service) *
Provide an explanation that includes why you were arrested, cited, detained, or charged; where you were arrested, cited, detained, or charged; when the event occurred (date); the outcome or disposition (for example no charges filed, charges dismissed, jail, probation, community service) *
Did you complete your probation or parole? Provide an explanation that includes why you were arrested, cited, detained, or charged; where you were arrested, cited, detained, or charged; when the event occurred (date); the outcome or disposition (for example no charges filed, charges dismissed, jail, probation, community service) *
How long were you in jail or prison for? (years, months, days specifically) Also provide an explanation that includes why you were arrested, cited, detained, or charged; where you were arrested, cited, detained, or charged; when the event occurred (date); the outcome or disposition (for example no charges filed, charges dismissed, jail, probation, community service) *
Explain what occurred, including the dates and location of the circumstances. *
Explain what occurred, including the dates and location of the circumstances. *
Explain what occurred, including the dates and location of the circumstances. *
Explain what occurred, including the dates and location of the circumstances. *
Explain which group(s) you served in, what occurred, including the dates and location of the circumstances. *
Explain and specify which one you served in, what occurred, including the dates and location of the circumstances. *
Explain what occurred, including the dates and location of the circumstances. Specify whether you used a weapon against another person and/or if you ever told a person that you would use a weapon against that person. *
Explain what you did, including dates and location of the circumstances, or what you intend to do. Also specify if you knew that this person was going to use the weapons against another person, and if you knew this person was going to sell, give, or provide the weapons to someone who was going to use them against another person: *
Explain what you did, including dates and location of the circumstances, or what you intend to do: *
Explain what occurred, including the dates and location of the circumstances. *
Explain what occurred, including the dates and location of the circumstances. *
Explain what occurred, including the dates and location of the circumstances. *
Explain what occurred, including the dates and location of the circumstances. *
Explain what occurred, including the dates and location of the circumstances. *
Explain what occurred, including the dates and location of the circumstances. *
Explain what occurred, including the dates and location of the circumstances. *
Explain what occurred, including the dates and location of the circumstances. *
Explain what occurred, including the dates and location of the circumstances. *
Explain what occurred, including the dates and location of the circumstances. *
Explain what occurred, including the dates and location of the circumstances. *
Explain what occurred, including the dates and location of the circumstances. *
Accommodation Request: *
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)