| Part 3. For Initial Requests Only |
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1.
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I initially arrived and established residence in the U.S.
prior to 16 years of age.
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2.
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Date of Initial Entry into the United States (on or about)
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3.
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Place of Initial Entry into the United States
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4.
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Immigration Status on June 15, 2012 (e.g., No Lawful
Status, Status Expired, Parole Expired)
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5.a.
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Were you EVER issued an Arrival-Departure Record
(Form I-94, I-94W, or I-95)?
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5.b.
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If you answered "Yes" to Item Number 5.a., provide
your Form I-94, I-94W, or I-95 number (if available)
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5.c.
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If you answered "Yes" to Item Number 5.a., provide the
date your authorized stay expired, as shown on Form I-94,
I-94W, or I-95 (if available).
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6.
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Indicate how you meet the education guideline (e.g.,
Graduated from high school, Received a general
educational development (GED) certificate or equivalent
state-authorized exam, Currently in school)
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7.
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Name, City, and State of School Currently Attending or
Where Education Received
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8.
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Date of Graduation (e.g., Receipt of a Certificate of
Completion, GED certificate, other equivalent state-
authorized exam) or, if currently in school, date of last
attendance.
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| Military Service Information |
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9.
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Were you a member of the U.S. Armed Forces or U.S.
Coast Guard?
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If you answered "Yes" to Item Number 9., you must provide
responses to Item Numbers 9.a. - 9.d. |
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Part 4. Criminal, National Security, and Public Safety Information (For Initial and Renewal
Requests) |
If any of the following questions apply to you, use Part 8.
Additional Information to describe the circumstances and
include a full explanation. |
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1.
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Have you EVER been arrested for, charged with, or
convicted of a felony or misdemeanor,including incidents
handled in juvenile court, in the United States? Do not
include minor traffic violations unless they were alcohol-
or drug-related.
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If you answered “Yes,” you must include a certified
court disposition, arrest record, charging document,
sentencing record, etc., for each arrest, unless
disclosure is prohibited under state law.
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2.
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Have you EVER been arrested for, charged with, or
convicted of a crime in any country other than the United
States?
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If you answered "Yes," you must include a certified
court disposition, arrest record, charging document,
sentencing record, etc., for each arrest. |
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3.
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Have you EVER engaged in, do you continue to engage
in, or plan to engage in terrorist activities?
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4.
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Are you NOW or have you EVER been a member of a
gang?
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5.
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Have you EVER engaged in, ordered, incited, assisted, or
otherwise participated in any of the following:
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5.a.
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Acts involving torture, genocide, or human trafficking?
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5.c.
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Severely injuring any person?
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5.d.
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Any kind of sexual contact or relations with any person
who was being forced or threatened?
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6.
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Have you EVER recruited, enlisted, conscripted, or used
any person to serve in or help an armed force or group
while such person was under age 15?
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7.
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Have you EVER used any person under age 15 to take
part in hostilities, or to help or provide services to people
in combat?
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