Email Address (required) 



Name of alien (family name, first, middle)

Address 

Type of visa 

Alien's birthdate (month/date/year) 

Birthplace (city or town, state or province & country) 

Present Nationality or citizenship 

Address in U.S. where alien will reside 

Name & address of prospective employer if alien has job offer in U.S. 

Occupation in which alien is seeking work

Alien will apply for a visa abroad at the American Consulate in _________ or Alien is in the U.S. and will apply for adjustment of Status in the office of the INS at _________.

Names & address of schools, colleges, & universities attended
 

Field of study 
From month & year to month & year 
Degrees of certificates received 


Work experience (list all jobs for past 3 years and any jobs related to the occupation for which the alien is seeking certification): 


Name & address of employer 

Name of job 

Date started (month & year) 

Date left (month & year)  

Kind of business 

Describe in detail the duties performed including the use of tools, machines or equipment

Number of hours per week