Immigration Information Center

Immigrant Visas Contact Form

Email Address

Applicant's Full Name:

Date of Birth:

Gender:

City/Town of Birth:

Country of Birth:

Mailing Address:

Phone Number:

Country of Eligibility (if your native country is not your country of birth):

Marital Status:

Number of unmarried children under the age of 21:

Highest level of schooling that you completed:

Any college/university degrees or specialized training or skills:

Spouse Information:

Name:

Date of Birth:

Gender:

City/Town of Birth:

Country of Birth:

Children Information:

(complete this information for each child who is unmarried and under the age of 21, including step-children and adopted children)

Name:

Date of Birth:

Gender:

City/Town of Birth:

Country of Birth:

Name:

Date of Birth:

Gender:

City/Town of Birth:

Country of Birth:

Name:

Date of Birth:

Gender:

City/Town of Birth:

Country of Birth:

Passport Information:

(for applicant, spouse and each unmarried child under the age of 21)

Passport Number:

Passport Country:

Expiration Date:

Describe the purpose of seeking an immigrant visa such as to obtain employment, to join family members, to obtain asylum or refugee status:

Are you interested in applying for an immigrant visa through the Diversity Visa Lottery Program?
Yes  No 

List of relatives in the United States:

List the legal status of these relatives:

Where do you plan to live in the United States?

Where will you be employed in the United States?

Name and address of employer:

Type of position you will take:

Date you expect to begin work:

Do you have any fear about returning to your country?

Please describe:

Have you previously applied for a United States visa?
Yes  No 

When:

Was your request granted?
Yes  No 

What type of visa did you receive?

What dates have you previously entered the United States?

Have you ever been removed or granted a voluntary departure?
Yes  No 

If yes, please describe:

Do you have any criminal history?
Yes  No 

If yes, please describe:

Special concerns:

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