Heather L. Poole, PC

(Toll Free) 1.877.HUMAN.RTS (486-2678)
Experts in Family-Based Immigration & Citizenship

First Name:
Middle Initial:
Last Name:
Have you ever used any other names? If so, write the name(s) here:
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Primary telephone:		( ) - ext.:
Work/Business Phone:			( ) - ext.:
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Address:
City:
Zip:	State:
E-mail Address:
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Social Security Number:
Date of Birth:	Year:
Where were you born:
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Education: Did you graduate from High School?				Yes No
Did you graduate from College?				Yes No
What college?
Degrees Earned:
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Have you ever been given public assistance (welfare)?				Yes No
Have you ever filed for bankruptcy?				Yes No
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Current Employer:
Employer City:
Employer State:
Job Title:
Do you work full-time or part-time?				Full Part
Yearly Salary:			$ Hourly Wage $
How long have you worked for this employer?				Years Months


	How did you hear about our firm? (Please check as many as applicable)
	Friend or Client (please list their name):
	Attorney (please list their name):
	Internet: Google Altavista lawyers.com Other website :
	Yellow Pages (check one, if you know):
	Domestic Violence Project at the courthouse:
	Other :
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	Your U.S. Immigration History:
When did you last enter the U.S.?				Year Month
Where did you enter?
Did you have a valid visa or border-crossing card when you entered the U.S.?				Yes No
1. If you had a visa, what kind of visa was it (i.e., visitor, student, etc.)?
2. Were you issued an I-94 (white card in your passport, informing you of how long you could legally stay in the U.S.)?				Yes No
3. When does/did your stay expire?
Have you (or anyone wanting to sponsor you) ever filed a prior visa petition?				Yes No
If YES, then answer the following:
Have you ever filed for Permanent Residence (a ?green card?) in the U.S.?				Yes No
Have you ever committed a crime?				Yes No
Have you ever been arrested?				Yes No
If answered YES to any of the above, give the following information:
Date:
Place (City/State/Country):
Nature of Offense:
Convicted?
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Have you ever committed a drug-related offense for which you were not arrested?				Yes No
Have you ever lied to an immigration officer?				Yes No
Been deported or excluded from the U.S.?				Yes No
Have you ever tried to enter the U.S. illegally (without a visa)?				Yes No
1. If yes, when? (list all attempts)
2. Were you caught by INS and fingerprinted?				Yes No
3. Did INS take you back to your home country?				Yes No
4. Did you attempt to or actually re-enter the U.S. illegally after you were fingerprinted?				Yes No
If, yes, when did this happen?
Have you ever been granted voluntary departure from an immigration judge but failed to depart within the voluntary departure time period granted?				Yes No
Have you ever used someone else's passport or green card to enter the U.S.?				Yes No
Have you ever claimed to be a U.S. citizen?				Yes No
Have you ever helped another immigrant to enter the U.S. illegally?				Yes No
Have you ever been treated in a facility as a mental patient?				Yes No
Do you hold nobility in any foreign state? Ties or lineage?				Yes No
Have you ever been a J visa nonimmigrant visitor and not complied with the 2-year foreign residence requirement or obtained a waiver?				Yes No
Have you ever engaged in prostitution in past 10 years, or likely to in future?				Yes No
Have you ever engaged in unlawful commercialized vice such as illegal gambling?				Yes No
Have you ever trafficked any unlawful drug into the U.S.?				Yes No
Have you ever been involved in any terrorist activity?				Yes No
Have you ever engaged in espionage (spy) or intend to once in the U.S.?				Yes No
Have you ever been a member of or affiliated with the Communist Party?				Yes No
Have you ever persecuted any person because of race, religion, national origin or political opinion?				Yes No
Left the U.S. to avoid being drafted into the U.S. Army?				Yes No
Have you ever registered under Selective Service?				Yes No
Have you ever applied for exemption from military service?				Yes No
Do you plan to marry more than one person at a time while in the U.S.?				Yes No
Are you currently subject to a child support order?				Yes No
Would you have any fear about your safety if you had to return to your home country, if deported?				Yes No
Have you been the victim of a serious crime in the U.S. or been taken to the U.S. against your will?				Yes No
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	Family History:
Are you a national or citizen of any country besides your country of birth?				Yes No
Are you currently married? If married, please answer the following:				Yes No
Is your spouse a U.S. citizen?				Yes No
Is your spouse a legal permanent resident?				Yes No
Has your spouse ever sponsored you for any immigration benefit or filed any immigration papers for you?				Yes No
Are you engaged to a legal permanent resident or U.S. citizen?				Yes No
Were you previously married to a legal permanent resident or U.S. citizen?				Yes No
If so, when were you divorced? (mo/year)
A. Is your mother a U.S. citizen?				Yes No
B. or a legal permanent resident?				Yes No
A .Is your father a U.S. citizen?				Yes No
B. or a legal permanent resident?				Yes No
Have you ever been abused by your spouse or parents? (financially, physically, or emotionally)				Yes No
Were any of your grandparents born in the U.S.?				Yes No
A. Do you have any children?				Yes No
B. If so, is your child(ren) a U.S. citizen?				Yes No
C. Or a legal permanent resident?				Yes No

By hitting the "submit" button, you agree that: (1) the above answers you have provided are true and accurate to the best of your knowledge and recollection; (2) this is a request for a free consultation; you are not required or bound in any way to accept any possible legal representation discussed in the consultation or to pay a consultation fee (THIS IS A COMPLETELY FREE CONSULTATION);(3) an attorney/client relationship has not been created by submission of this form; you agree that this form is for free consultation purposes only and no attorney/client relationship will attach until a written engagement agreement is signed between you and our office (signed by Attorney Heather L. Poole) and any legal fees are received after conclusion of the consultation IF you and our firm agree on representation for a legal service; and (4) this form once submitted will be routed to our office for the Attorney's review. A member of our staff will contact you shortly to set up a free confidential consultation for you with Attorney Heather L. Poole. Thank you.