U.S. Consultation Questionnaire (Individual)

Please be aware that this form is for US immigration consultations only. Do not use this questionnaire for Canadian immigration consultations. If you require assistance with a Canadian immigration matter, please complete Henry J. Chang's Canadian Consultation Questionnaire (Individual).

The information submitted in this SSL encrypted questionnaire will be kept confidential. Once you have submitted your completed form, you will have an opportunity to schedule your consultation online.

Please note that initial consultations last up to one hour and a flat fee of $945.00 CAD (plus applicable GST/HST) will apply. However, certain consultations (such as those involving inadmissibility or citizenship claims) require additional analysis and are instead billed on a hourly basis. In such cases, you will be informed in advance that your initial consultation will exceed $945.00 CAD (plus applicable GST/HST) and you will be given an opportunity to confirm whether you still wish to proceed.

Once you have scheduled your consultation, we will contact you in order to request your credit card information. The initial consultation fee (plus GST/HST, if applicable) must be paid before your consultation takes place.

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REFERRAL INFORMATION

Were you referred to Henry Chang? Yes No

If yes, who referred you?

OBJECTIVE

Briefly describe what you would like us to do for you:

COMPANY INFORMATION (IF APPLICABLE)

If you will be requesting that the consultation fee and/or any subsequent fees be billed to a business entity, please provide the following information:

General Information

Full Name of Corporation/Company/Partnership/Proprietorship:

Corporation Number/Federal Tax ID Number/Employer Identification Number:

United States Address of Corporation/Company/Partnership/Proprietorship

Street and Suite Number:

City:

State:

Zip Code

Address of Corporation/Company/Partnership/Proprietorship Outside the United States (If Applicable)

Street and Suite Number:

City:

Province or State:

Postal or Zip Code:

Country:

Foreign Business Telephone:

Foreign Business Fax:

PERSONAL INFORMATION

E-mail Address (It is essential that this address be correct):

E-mail Address (Enter Your E-Mail Again):

Family Name:

First Name:

Middle Name:

Other Names Used (If married woman, give maiden and surnames of any previous spouses):

Birthdate (Month/Date/Year):

City & Country of Birth:


Marital Status: Single Married Widowed Divorced

Sex (M/F): Male Female

ADDRESS INFORMATION

United States Address

Street and Suite Number:

City:

State:

Zip Code

Home Phone:

Business Phone:

Fax:

Permanent Address Outside the United States

Street and Suite Number:

City:

Province or State:

Postal or Zip Code:

Country:

Home Phone:

Business Phone:

Fax:

If you are not currently a resident of Canada, we will need to determine whether you are subject to Goods and Services Tax/Harmonized Sale Tax. Please confirm the date that you formally became a non-resident for tax purposes and describe in detail any ties that you (or any business in which you may own an interest) have continued to maintain in Canada since that date:

VISA AND PASSPORT INFORMATION

Passport

Issued by (Country):

Issue Date:

Expiry Date:

Passport Number:

Visas

Current Visa Held:

Date Admitted:

Visa Expiry Date:

Previous Visa Held:

Date Admitted:

Visa Expiry Date:

Alien Registration Number (Begins with the Letter "A"):

U.S. Social Security Number (Not Canadian Social Insurance Number):

I-94 Number:

I-94 Expiry Date:

Last Entry into U.S (When, Where, Name of Carrier):


Have you ever applied for permanent resident status? Yes No

If yes, please provide details:

Are you an American Indian born in Canada having least
50 per centum of American Indian blood? Yes No

SPOUSE INFORMATION

Personal Information of Spouse

Family Name:

First Name:

Birth Date: (MM/DD/YY):

Address of Spouse

Street and Suite Number:

City:

Province or State:

Country:

Spouse's Occupation:

Spouse's Alien Registration Number (Begins with the Letter "A"):

Social Security Number:

Spouse's Passport

Issued by (Country):

Expiry Date:

Passport Number:

Spouse's Visa Status

Current Visa Held:

Date Admitted:

Visa Expiry Date:

Previous Visa Held:

Date Admitted:

Visa Expiry Date:

Has your spouse ever applied for permanent resident status? Yes No

Is your spouse an American Indian born in Canada having least
50 per centum of American Indian blood? Yes No

CHILDREN INFORMATION

First Child's Name:

City and Country of Birth of First Child:

Birthdate (MM/DD/YY) of First Child:


Second Child's Name:

Second Child's City and Country of Birth:

Second Child's Birthdate (MM/DD/YY):


Do you have any other children? If so, please list their name, city and country of birth, and birthdate below:

EDUCATION

Describe your educational backround, listing the name and address of all schools, colleges, or universities attended beginning with your high school education, the dates of attendance at the school, the field of study and the degree or certificate received.

If you are licensed in any profession, please list location and date of licensure. Please indicate if license currently valid.

What languages do you speak?

Describe any special qualifications, skills, proficiency in use of tools, machines, equipment or technology:

RELATIVES IN THE UNITED STATES

Please list at least three of your closest relatives in the United States (if any) and state their relationship to you, their immigration or citizenship status (e.g. U.S. citizen, permanent resident, etc.), their address and their phone number:

OCCUPATIONAL INFORMATION

What is your current occupation?:

If you have a job offer, give name and address of prospective employer:

What is the title of the proposed job and what will be your main duties?

What is your proposed salary?

Describe in full all jobs whether in the United States or overseas beginning with present job. Be sure to list the employer's name, address, type of business, your job title, a description of your work, your ending salary and the dates of your employment.

POSSIBLE GROUNDS OF INADMISSIBILITY

Note: If you answer "yes" to any of the following questions, please explain in detail in the area for additional information which appears below.

Have you or any family member ever made a fraudulent statement or misrepresented a fact to obtain or try to obtain any immigration benefit from the U.S?
Yes No

Have you ever been afflicted with a communicable disease of public health significance, a dangerous physical or mental disorder, or been a drug abuser or addict?
Yes No

Have you ever been arrested or convicted for any offense or crime, even through subject of pardon, amnesty, or other such legal action?
Yes No

Have you ever been a controlled substance (drug) trafficker?
Yes No

Have you ever been a prostitute or procurer of prostitutes?
Yes No

Were you excluded or deported from the United States within the last 20 years?
Yes No

Do you seek to enter the United States to engage in export control violations, subversive or terrorist activities or any unlawful purpose?
Yes No

Have you ever ordered, incited, assisted, or otherwise participated in the persecution of any person because of race, religion, national origin, or political opinion under the control, direct or indirect, of the Nazi Government of Germany, or of the government of any areas occupied by, or allied with, the Nazi Government of Germany, or have you ever participated in genocide?
Yes No

ADDITIONAL INFORMATION

Give any additional information about yourself here which would help you establish your qualifications (List professional licenses, awards, prizes, membership in professional organizations, etc.) or explain your answers to the above questions:

MAINTENANCE OF LAWFUL PERMANENT RESIDENCE
(Complete only if you are already a lawful permament resident of the United States.)

Please describe all absences from the United States since you first acquired lawful permanent residence:

If you have ever failed to file a U.S. income tax return as a resident since you first acquired lawful permanent residence? If so, please provided details:

UNITED STATES CITIZENSHIP MATTERS
(Complete only if you are already a United States citizen or interested in seeking United States citizenship)

Are you a lawful permanent resident of the United States interested in applying for United States citizenship? If so, please provide further detais of your eligibility below:

Do you have a parent who was born in or is a citizen of
the United States? Yes No

For each U.S. citizen parent, please provide the date and manner (i.e. naturalization, birth in the U.S., birth abroad) in which they became United States citizens:

For each U.S. citizen parent, please state the years that they were physically present in the United States prior to your birth:

Does your spouse have a parent who was born in or is a citizen of
the United States? Yes No

For each U.S. citizen parent of your spouse, please provide the date and manner (i.e. naturalization, birth in the U.S., birth abroad) in which they became United States citizens:

For each U.S. citizen parent of your spouse, please state the years that they were physically present in the United States prior to your birth:

Are you currently a United States citizen who believes that you may have previously lost citizenship or are you seeking to renounce your citizenship now? If so, please provide further details below:

PLEASE READ THE FOLLOWING STATEMENTS PRIOR TO SUBMITTING YOUR QUESTIONNAIRE. SUBMISSION OF THIS QUESTIONNAIRE INDICATES THAT YOU ACCEPT THE FOLLOWING TERMS:

1. You confirm that, to the best of your ability, you believe that the information contained in this questionnaire is truthful and correct.
2. You confirm that the submission of this questionnaire does not create any obligation for yourself or for the lawyer with whom you wish to request a formal consultation.
3. You confirm that submission of this questionnaire does not create an attorney-client relationship and that the lawyer is not obliged to schedule a consultation with you.