Immigration Intake Form reCAPTCHA First Name MI Last Name Street Address Address Line 2 A "Safe" Mailing Address (leave blank if same as Street Address) City State Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Home Phone Business Phone Cell Phone Email Address Date of Birth (MM/DD/YYYY) City and Nation of Birth Nationality Other Citizenship? Yes No Please Specify A Number (green card or work permit) I94 Number Type of Non-Immigrant Visa (visitor, fiancé, student, etc.) Date of First Entry to U.S. (MM/DD/YYY) Place of First Entry to U.S. Date of Last Entry to U.S. (MM/DD/YYY) Place of Last Entry to U.S. Are you known by any other names? (Include maiden or native alphabetic spelling.) Yes No List other names you have used Are you currently married? Yes No Is your spouse a U.S. Citizen? Yes No Do you have any children? Yes No How many children do you have? Are any of your children U.S. Citizens? Yes No Do you have a job or offer from a U.S. employer? Yes No Please provide the employer's name and address, and a description of the job you have been offered. Do you have family members now living in the U.S.? Yes No Please provide the name and address of your family member, and describe how you are related to that family member. Please set out the reason(s) you wish to enter, or remain in, the U.S. If you are applying for a visa to enter the U.S., do you wish to bring members of your family with you? Yes No Have you ever entered the U.S. on a visa other than a tourist visa? Yes No Please provide the dates you were in the U.S., and the type of visa used. Have you ever been denied permission to enter the U.S., or ordered to leave the U.S.? Yes No Please give the reason and the relevant dates. Have you ever been convicted of a crime (other than non-criminal traffic offense)? Yes No Please provide the details, including the offense for which you were convicted, the sentence or penalty imposed, and the date of the offense. If you are now in the U.S., have you been ordered to leave, or do you believe you may be ordered to leave? Yes No Please provide the details, including the reason for the order. Are you making a claim for political asylum? Yes No Please provide the details, including the reasons for your claim. Have other attorneys worked on this matter? Yes No Please provide the details, including the reasons for your claim.