Questionnaire

Background Questionnaire for Those Seeking Employment, a Work Visa or to Immigrate to the U.S.

Enter Secret code *:

Personal Data

First Name *:

Last Name *:

Date of Birth *:

Place of Birth (country, city) *:

Citizenship *:

Address:

Phone (including country and area code):

E-mail *:

Family Information

Marital Status:

Name and Age of spouse (if applicable):

Number of children/ages:

Education

Name of Institute, Location of Institute, Specialty, Years attended/graduated:

Post-graduate education (if any):

Other training/courses/certifications:

Work Experience

Employment (please specify if you have ownership interest in business/employer), dates, position, description of duties:

Achievements

Awards/Publications/Patents/Memberships in Associations/Honors/Conference appearances:

Language (English)

don't know *:

Speak:

Read:

Write:

Language (French)

don't know *:

Speak:

Read:

Write:

Spouse (if applicable)

Spouse's Education:

Spouse's Professional Background:

Potential Employer

If applicable, potential Employer in US/Canada (Company Name, Address):

Relatives

Any family members in US/Canada? If yes, please specify (what? Names, ages?) and their status:

Past Travels

US * :

— Yes
— No

Canada * :

— Yes
— No

If yes, when? What kind of visa? How long were you there for?:

Have you ever been rejected for visa? (If yes, why?):

Assets

Assets for relocation *:

Other Issues

Any medical/criminal/security issues? If Yes, please detail::

Special Notes/Comments/Questions::

* - must be filled in