INFORMATION ABOUT THE APPLICANT/BENEFICIARY

1.Your Email:

2.Your Last Name:

3. Your First Name:

4. Your Full Middle Name:

5. Your Birthdate:

6. Your Place of Birth (city, province, country):

7. The Full Name, Date of Birth and Place of Birth of Your Husband/Wife (if any):

8. The Full Names, Dates of Birth and Places of Birth of Your Children:

9. Your Foreign Residence Address:

10. Your U.S. Residence Address:

11. Tel:

12. Fax:

13. Your E-Mail Address:

14. Social Security Number:

15. I-94 Issue Date:

16. I-94 Expiration Date:

17. Current Status:

Check Only One of the Following (18-22)

18. Is This New Employment?

19. Continutuation of Previously Approved Employment?

20. New Concurrent Employment?

21. Change of Employer?

22. Amended Petition?

23. If You Currently Hold Non-Immigrant Status Please Provide Your Previous INS (USCIS) Case Receipt Number:

24. Work Experience:

25. Academic Background:

26. Applicant's/Beneficiary's or Dependents Prior Periods of Stay in the U.S. with H Classifications:

27. Have You Applied Before for an H-1B1 Visa?

28. If So, What Was the Outcome?

29. Have You Ever Applied for an Immigrant Visa?

30. If So, Please Provide Details:

INFORMATION ABOUT THE POSITION OFFERED

31. Title.

32. Duties and Responsibilities

33. Salary:

INFORMATION ABOUT THE U.S. EMPLOYER

34. Name and Address.

35. Number of Employees.

36. Year Established.

37. Gross and Net Income.

38. General Description of Business Activities.

39. Name and Title of Signing Officer.