Questionnaire For Us Citizen

Biographic data for U.S.
Citizen
1. NAME: _____________________________________________________________________
FIRST NAME MIDDLE LAST NAME
2. OTHER NAMES USED: _______________________________________________________
3. FULL NAME IN NATIVE ALPHABET (IF ROMAN LETTERS ARE NOT USED):
____________________________________________________________________________
4. DATE OF BIRTH: ____________________________________________________________

MONTH / DAY / YEAR HEIGHT / WEIGHT EYE COLOR / HAIR COLOR
5. PLACE OF BIRTH: ___________________________________________________________

CITY OR TOWN PROVINCE COUNTRY
6. NATIONALITY: ______________________________________________________________
7. GENDER (check one): ____ MALE ____FEMALE
8. MARITAL STATUS (check one): ____SINGLE ____MARRIED

____DIVORCED ____WIDOWED ____SEPARATED
9. HOW MANY TIMES HAVE YOU BEEN MARRIED (including present marriage): ________
10. CURRENT ADDRESS:

____________________________________________________________________________
NUMBER STREET CITY STATE ZIP CODE
____________________________________________________________________________
COUNTRY TELEPHONE NUMBER E-MAIL
11. PRESENT OCCUPATION: _____________________________________________________
12. NAME OF SPOUSE: __________________________________________________________
13. DATE & PLACE OF MARRIAGE: _______________________________________________
14. FATHER’S INFORMATION:
NAME: _______________________________________________________________
FIRST MIDDLE LAST
DATE OF BIRTH: ______________________________________________________

MONTH / DAY / YEAR
PLACE OF BIRTH: _____________________________________________________

CITY OR TOWN COUNTRY
CURRENT ADDRESS: __________________________________________________

IF DECEASED, GIVE YEAR OF DEATH: __________________________________

Biographic Data
Page 2
15. MOTHER’S INFORMATION:
NAME: _______________________________________________________________
FIRST MIDDLE LAST (MAIDEN NAME)
DATE OF BIRTH: ______________________________________________________

MONTH / DAY / YEAR
PLACE OF BIRTH: _____________________________________________________

CURRENT ADDRESS: __________________________________________________

IF DECEASED, GIVE YEAR OF DEATH: __________________________________
16. LIST THE PLACES YOU HAVE LIVED FOR THE LAST FIVE (5) YEARS:
STREET & NUMBER CITY OR TOWN PROVINCE COUNTRY FROM/TO
(month & year)
_______________________ _________________ _____________ ________________ ___________
_______________________ _________________ _____________ ________________ ___________
_______________________ _________________ _____________ ________________ ___________
_______________________ _________________ _____________ ________________ ___________
_______________________ _________________ _____________ ________________ ___________
_______________________ _________________ _____________ ________________ ___________
_______________________ _________________ _____________ ________________ ___________
17. LIST ALL EMPLOYMENT FOR THE LAST 5 YEARS:

EMPLOYER LOCATION JOB TITLE FROM/TO (month & year)
__________________________ ___________________ ___________________ _________________
__________________________ ___________________ ___________________ _________________
__________________________ ___________________ ___________________ _________________
__________________________ ___________________ ___________________ _________________
__________________________ ___________________ ___________________ _________________
__________________________ ___________________ ___________________ _________________
__________________________ ___________________ ___________________ _________________
18. SOCIAL SECURITY NUMBER: ____ ____ ____ - ____ ____ - ____ ____ ____ ____
19. HOW WAS YOUR CITIZENSHIP ACQUIRED (please check one):

______ Birth in the United States
______ Naturalization
______ Parents
I hereby acknowledge that the above is true and correct to the best of my knowledge.
_________________________________ ___________________________
SIGNATURE DATE

Questionnaire For Us Citizen

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Biographic data for U.S.

2. OTHER NAMES USED: _______________________________________________________

4. DATE OF BIRTH: ____________________________________________________________

5. PLACE OF BIRTH: ___________________________________________________________

7. GENDER (check one): ____ MALE ____FEMALE

8. MARITAL STATUS (check one): ____SINGLE ____MARRIED

10. CURRENT ADDRESS:

11. PRESENT OCCUPATION: _____________________________________________________

12. NAME OF SPOUSE: __________________________________________________________

13. DATE & PLACE OF MARRIAGE: _______________________________________________

14. FATHER’S INFORMATION:

DATE OF BIRTH: ______________________________________________________

PLACE OF BIRTH: _____________________________________________________

CURRENT ADDRESS: __________________________________________________

IF DECEASED, GIVE YEAR OF DEATH: __________________________________

15. MOTHER’S INFORMATION:

DATE OF BIRTH: ______________________________________________________

PLACE OF BIRTH: _____________________________________________________

CURRENT ADDRESS: __________________________________________________

IF DECEASED, GIVE YEAR OF DEATH: __________________________________

17. LIST ALL EMPLOYMENT FOR THE LAST 5 YEARS:

19. HOW WAS YOUR CITIZENSHIP ACQUIRED (please check one):

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7. GENDER (check one): MALE FEMALE

8. MARITAL STATUS (check one): SINGLE MARRIED