11
Please answer all questions completely. Do not leave blank spaces. Write ‘N/A’ if a question does not pertain to the applicant. Please fill out a separate form for each member of your case.
1. Applicant’s name (in English):
2. Date of Birth:
3. City of Birth:
4. Country of Birth:
Note: Names, places of birth and dates of birth should be written in English as they appear on the individual’s passport or other primary documents such as ID cards, birth certificates, marriage certificates, etc.) Please do not use abbreviations.
5. Ethnicity (example: Arab, Assyrian, Kurd, etc.):
6. Religion (example: Sunni, Shiite, Catholic, etc.):
7. Nickname:
8. Tribal Name:
9. Any other names:
10. Marital status (single, divorced, widowed or married):
11. Number of marriages (how many times did applicant get married?):
12. Date of applicant’s current marriage:
13. Name of your applicant’s spouse:
14. Date of birth of applicant’s current spouse:
15. Place of birth of applicant’s current spouse (country and city):
16. Will applicant’s current spouse travel with applicant? Yes or No
17. In the table below, please indicate all of the applicant’s previous marriages:
Name of previous spouse
Place of birth
Date of birth
Marriage date
Date of termination of marriage
Location (indicate if died, killed or location not known)
If deceased, date spouse died
If killed, date spouse was killed
If location unknown, date / place spouse last seen
18. Please fill in biographical information for the applicant’s father:
a. First name father:
b. Middle name father:
c. Last name father:
d. City and Country of father’s birth:
e. Date of father’s birth:
f. Nationality of father:
g. Number of marriages father had:
h. Location of father:
i. If father is deceased, date and location of death:
j. If father was killed, date and location father was killed:
k. If location of father is unknown, date and place father was last seen:
l. Date of father’s marriage to mother, if they were married:
19. Please fill in biographical information for the applicant’s step-father, if applicant has one:
a. First name father:
b. Middle name father:
c. Last name father:
d. City and Country of father’s birth:
e. Date of father’s birth:
f. Nationality of father:
g. Number of marriages father had:
h. Location of father:
i. If father is deceased, date and location of death:
j. If father was killed, date and location father was killed:
k. If location of father is unknown, date and place father was last seen:
l. Date of father’s marriage to mother, if they were married:
20. Please fill in biographical information for the applicant’s mother:
a. First name mother:
b. Middle name mother:
c. Last name mother:
d. City and Country of mother’s birth:
e. Date of mother’s birth:
f. Nationality of mother:
g. Number of marriages mother had:
h. Location of mother:
i. If mother is deceased, date and location of death:
j. If mother was killed, date and location mother was killed:
k. If location of mother is unknown, date and place mother was last seen:
l. Date of mother’s marriage to father, if they were married:
21. Please fill in biographical information for the applicant’s step-mother, if applicant has one:
a. First name mother:
b. Middle name mother:
c. Last name mother:
d. City and Country of mother’s birth:
e. Date of mother’s birth:
f. Nationality of mother:
g. Number of marriages mother had:
h. Location of mother:
i. If mother is deceased, date and location of death:
j. If mother was killed, date and location mother was killed:
k. If location of mother is unknown, date and place mother was last seen:
l. Date of mother’s marriage to father, if they were married:
22. Please list the applicant’s children, from eldest to youngest. Include all children who are deceased, killed or location is unknown:
Child’s name
Date of birth
Place of birth
Name of child’s other parent
Location (please indicate if deceased, killed or location unknown)
Will child travel with applicant?
Religion of child
Marital status of child (married, single, widowed, divorced)
If deceased, date child died
If killed, date child was killed
If location unknown, date / place child last seen
23. Please list the applicant’s siblings, from eldest to youngest. Include the applicant in the list:
Sibling’s name
Male or Female?
Mother’s name / Father’s name
Date of birth
Place of birth
Location (please indicate if deceased, killed or location unknown)
Marital status (married, single, widowed, divorced)
Number of marriages
If deceased, date died
If killed, date killed
If location unknown, date / place last seen
24. Does applicant have any medical conditions? If yes, list all medical conditions, type of medications applicant is currently using, and attach related medical reports, if any.
Medical condition
Medication currently being used
Medical report attached? (Yes or No)
Pregnancy (Yes or No)
If yes, months of pregnancy
25. Starting with the most recent address, indicate your residence during the last 5 years:
Country
Province
City
District
Neighbor-hood
Sector
Street
Bldg #
Address type (current or previous)
Date started living at address (use DD/MM/YY format)
Date stopped living at address (use DD/MM/YY format)
26. Starting with the most recent, list all educational institutions applicant has attended since birth, including non-degree programs and vocational trainings:
Institution or School Name
Institution Type (Primary School, Intermediate school, Secondary school, University/faculty, or Vocational Training)
Country
City
Date started at school (use DD/MM/YY format)
Date ended at school (use DD/MM/YY format)
Did you complete the school?
(Yes or No)
Field of study
Diploma received? (Example: BA, BS, Diploma, etc.)
27. List the languages the applicant speaks:
Language
Speaking ability (none, some or good)
Reading ability (none, some or good)
Writing ability (none, some or good)
Is this the applicant’s native language? (Yes or No)
28. List the professions the applicant has had during the last five years:
Occupation or Skill (Title)
Employer Name
Country
City
Start date of employment (use DD/MM/YY format)
End date of employment (use DD/MM/YY format)
29. Has the applicant ever worked with the government, at any time in his/her life? If yes, please give full details:
Title
Employer’s Name / Government office
Country
City
Start date (use DD/MM/YY format)
End date (use DD/MM/YY format)
30. Has the applicant ever joined the military, been called to perform compulsory military service, or trained in a military school or under the public army (like the Al Qudes Army)? If yes:
Branch/Organization
Start date of service (use DD/MM/YY format)
End date of service (use DD/MM/YY format)
Rank Attained
Country
Comments
31. Has the applicant ever been arrested in Iraq or any other country, including any arrest by multi-national forces? Has the applicant ever committed any type of law violation? If yes:
Nature of the arrest or law violation committed
Arrest date (use DD/MM/YY format)
Release date (use DD/MM/YY format)
Country
Comments
32. Has the applicant ever been held for interrogation by any authority without being detained? If yes:
Nature of Interrogation
Date of interrogation
Number of hours being held for interrogation
Country
Comments
33. Indicate any political, professional or social organization that the applicant has ever joined, or been forced to join, including the Baath party:
Organization Name
Start date
End date
Location
Comments
34. Have the applicant ever traveled to the U.S? If yes:
Entry date (use DD/MM/YY format)
Departure date (use DD/MM/YY format)
Purpose of the visit
Alien Number
35. Please list all contact information (work or home phones, mobile phones, other/unknown phone, work and home email addresses and fax numbers) that the applicant has used during the past five years:
Contact type: choose home phone, work phone, mobile phone, other phone, unknown phone, personal e-mail, work e-mail, other email, fax, pager, or TDD / TTY
Start date (use DD/MM/YY format)
End date (use DD/MM/YY format)
Comments
36. Does the applicant have any friends or relatives in the U.S with whom he or she is willing to be resettled? If yes, please provide us with their full contact information and the receiving agency in the U.S will make all possible efforts to resettle the applicant in the same as the U.S. friend or relative. Note: it is very important you fill in all information for the applicant’s resettlement preferences:
Resettlement preference #1
Relative or friend’s name:
Relation to applicant:
U.S resident (yes or no):
Marital status:
Number of marriages:
Street name:
City:
State:
Zip Code:
Telephone number:
Resettlement preference #2
Relative or friend’s name:
Relation to applicant:
U.S resident (yes or no):
Marital status:
Number of marriages:
Street name:
City:
State:
Zip Code:
Telephone number:
Resettlement preference #3
Relative or friend’s name:
Relation to applicant:
U.S resident (yes or no):
Marital status:
Number of marriages:
Street name:
City:
State:
Zip Code:
Telephone number:
37. Please list any other information you think is important to your case.
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