h-1b, o-1 & pr beneficiary information for all h-1b, o-1 ... beneficiary form... · h-1b, o-1...
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H-1B, O-1 & PR Beneficiary Information for all H-1B, O-1 & PR applications
*PLEASE SUBMIT THIS FORM TO YOUR SPONSORING DEPARTMENT TO BE
INCLUDED WITH THE H-1B, O-1 or PR APPLICATION*
The following information is required for the preparation of the H-1B, O-1, or PR petition on your behalf. Answer all relevant questions. Failure to complete all relevant questions or writing unclearly may delay the filing of your application.
Personal Information
Must be filled out completely. If it does not apply to you, please write “N/A.” Do not leave any spaces blank.
1. Legal name (as it appears on your passport)
Surname (Last Name): _________________________________________________________
Given Name (First/Middle Name): ________________________________________________
2. Other names used, including maiden names, shortened names, secondary last names, previous names from other marriages, alternative published names, or any Anglicized names. ________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
3. Date of birth: __________________ ______ ________
4. Gender: Male Female
5. Marital Status: Single Married
6. U.S. Social Security Number (if you have worked in the U.S. previously): ___________ N/A
7. Country of birth: _______________________________________________
8. Province of birth: ______________________________________________ N/A
9. Country of permanent residence: __________________________________
10. Country of citizenship or nationality: ___________________________________________
11. Do you currently live in the U.S.? Yes No If yes, please provide your current address: Street number and name: _________________________________________________________________
Apartment #____ Suite #____ Floor #____ City or Town: ________________________________ State: _______________________ ZIP: ___________
12. E-mail address: _____________________________________________________
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Passport Information
Do you have a valid passport*? Yes No *Passports must be valid for at least 6 months past the start date of this petition. If it is not, we recommend renewing your passport before we will submit the petition.
Do you have more than one passport? Yes No If yes, which passport are you going to use for this petition? ______________________________ Please list all current passports below: Passport 1 Passport number: _________________________________
Country that issued your passport: ________________________________ Passport issue date (mm/dd/yyyy): ________________________________ Passport expiration date (mm/dd/yyyy): ____________________________
Passport 2 Passport number: _________________________________
Country that issued your passport: ________________________________ Passport issue date (mm/dd/yyyy): ________________________________ Passport expiration date (mm/dd/yyyy): ____________________________
Future Travel Plans
Do you or your dependents have plans to travel to/from the U.S. in the next 6 months? Yes No
If yes, dates of travel: ________________________ where? ___________________________
*Traveling ǿƘile certain petitions are pending with U.S. Citizenship and Immigration Services (USCIS) may be an issue. Please speak to IFSS about your pending travel plans as soon as possible.
Filing Information
Are you currently or will you be inside the U.S. when this petition is filed? Yes (skip to next section) No If you will apply for your visa stamp abroad, please list the city and country of the U.S. consulate/embassy (http://www.usembassy.gov/) where you will/would apply for the visa:
City: ______________________________ Country: ______________________________
Please provide a foreign residential/home address (can be a parent, relative, friend, etc. if you do not have one) Street number and name: _________________________________________________________________
Apartment #____ Suite #____ Floor #____ City or Town: _______________________________________ State: _______________________________ Province: ___________________________________ N/A Postal code: ___________________ N/A Country: _____________________________________
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Family Information
Do you have a dependent spouse and/or children? Yes No (if no, please skip to next page) Number of Dependent Spouse and Children: _____ *Defined as a legally married spouse or children under the age of 21 and who were born outside the U.S.
Please choose one of the below: My dependents are inside the U.S. and will need to file the form I-539 to petition for their H-4 status. My dependents are outside the U.S. and do not need to file the I-539. They will use my I-797 approval
notice to get their H-4 status when entering the U.S. My dependents do not require H-4 status. Please explain: ______________________________
_____________________________________________________________________________
_____________________________________________________________________________
Please list the names of all dependents (spouse and children): Dependent 1 Relationship: Spouse Child Country of birth: _____________________________
Legal name (as it appears on your passport) Country of citizenship: ________________________
Surname (Last Name): _________________________________________________________
Given Name (First/Middle Name): ________________________________________________
Date of birth: __________________ ______ ________
Gender: Male Female
Dependent 2
Relationship: Spouse Child Country of birth: _____________________________
Legal name (as it appears on your passport) Country of citizenship: ________________________
Surname (Last Name): _________________________________________________________
Given Name (First/Middle Name): ________________________________________________
Date of birth: __________________ ______ ________
Gender: Male Female
Dependent 3
Relationship: Spouse Child Country of birth: _____________________________
Legal name (as it appears on your passport) Country of citizenship: ________________________
Surname (Last Name): _________________________________________________________
Given Name (First/Middle Name): ________________________________________________
Date of birth: __________________ ______ ________
Gender: Male Female
If you have more dependents, please print and complete another page
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Education Information
Did you obtain your highest degree from a U.S. Institution? Yes No Have you graduated? Yes, I graduated in: _______________ (list year) No Please list your highest degree only below:
Type of Degree: ___________________________
Name of university: ______________________________________________________________________
Major/ Primary Field of study: ______________________________________________________________
Address of university:
City or Town: _______________________________________ State: _______________________________ Province (if not in the US): ___________________________ N/A Postal code: ____________ N/A Country (if not in the US): _____________________________________
Does your position require you to obtain licensure in the State of Wisconsin? Yes No
If yes, have you obtained Wisconsin licensure? Yes No In process
For employees who will have direct human patient contact:
Are you a graduate of a foreign medical school? Yes No
Have you passed all three steps of the U.S. Medical Licensing Exam (for MDs) or the NBOME COMLEX-USA (for
DOs)? Yes No In process
If no, please explain: _______________________________________________________________
________________________________________________________________________________
Have you obtained certification from the Educational Commission for Foreign Medical Graduates (ECFMG)?
Yes
No
No, I am a graduate from a U.S. or Canadian medical school and do not require ECFMG certification
In process
Credential Evaluation
Please note that a credential evaluation is now required for all diplomas granted from colleges, universities and institutions outside the U.S. and Canada. It will be the responsibility of either the beneficiary or the department to obtain the credential evaluation. NACES (National Association of Credential Evaluation Services) can provide you with a list of accredited services to get your foreign studies evaluated: http://naces.org/members.html. You can also find other services that are not accredited by doing an online search. IFSS cannot recommend one company over another. NOTE: Foreign medical graduates who have ECFMG certification do not need an additional credential evaluation.
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Current Immigration Status NOTE: I-94’s are now found online at www.cbp.gov/i94
Current Immigration Status: _______________ Date of last arrival in the U.S. (mm/dd/yyyy): _____________ Date status expires (mm/dd/yyyy) - look on your DS-2019, I-20 or I-797: ________________ I-94 Number: ______________________________ I-94 Expiration Date (mm/dd/yyyy or D/S): ________________ Immigration status on I-94 card (may be different than current status): ________________________ Are you currently in removal proceedings? Yes No
Immigration Status History
1. Have you EVER been in H-1B or O-1 status in the past? Yes No (if no, skip to question 2)
Which status? H-1B O-1 Have you ever been denied? Yes No
If yes, please explain: _____________________________________________________________ _______________________________________________________________________________
Provide all receipt numbers & expiration dates (see sample on first line below). Receipt number: WAC-12-123-12345_ Validity dates (mm/dd/yyyy): 01/01/2015 – 12/31/2018_________ Receipt number: __________________ Validity dates: _______________________________ Receipt number: __________________ Validity dates: _______________________________ Receipt number: __________________ Validity dates: _______________________________ Receipt number: __________________ Validity dates: _______________________________ Receipt number: __________________ Validity dates: _______________________________ Dates when you have been physically present inside the U.S. in H-1B or O-1 Status. DO NOT list the validity
dates of your H-1B statuses (as you did above). Attach a separate sheet if needed. From (mm/dd/yyyy): _3/15/2015 (date you entered the U.S.) To (mm/dd/yyyy): _4/6/2015 (date you left the U.S.)
From: _______________ To: ________________ From: _______________ To: ________________ From: _______________ To: ________________ From: _______________ To: ________________ From: _______________ To: ________________ From: _______________ To: ________________
2. Have you EVER been in F-1 status in the past? Yes No (if no, skip to question 3) Expiration date or end date of I-20 (mm/dd/yyyy): _____________________ Are you currently on OPT (Optional Practical Training)? Yes No
If yes, what is end date listed on your Employment Authorization Document (EAD) card (mm/dd/yyyy): _________________ EAD card number (starts with LIN, WAC, EAC, SRC, MSC): ________________________
Student & Exchange Visitor Information System (SEVIS) #: N______________________________
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3. Have you EVER been in J-1 or J-2 status in the past? Yes No (if no, skip to question 4)
Student & Exchange Visitor Information System (SEVIS) #: N_________________________________ Expiration date or end date of DS-2019 (mm/dd/yyyy): _____________________ J-1 Category (student, professor, research scholar, etc.): ________________________ Are you subject to the two-year home residence requirement? Yes No
If yes, have you applied for a waiver? Yes No* If yes, have you received the Department of State recommendation? Yes No* If yes, have you received the USCIS I-612 approval notice? Yes No*
*If no, we will not be able to process your H-1B application until such time as you receive the I-612 approval notice from U.S. Citizenship and Immigration Services.
4. Are you CURRENTLY in B-1/B-2 status? Yes No (if no, skip to question 5)
Which status: B-1/B-2 WB/WT (this indicates you were admitted on the Visa Waiver Program) Expiration date or end date (on I-94 card; mm/dd/yyyy): _____________________
5. Are you currently in the process of applying for Permanent Residency? Yes No (if no, skip to
signature space) Has a labor certification been filed on your behalf by a U.S. employer? Yes No If yes, please provide the following: Date of filing (mm/dd/yyyy): _________________________ Name of employer: _______________________________________________________
The labor certification is/has been: Certified In Process Denied Has an immigrant petition (I-140 or I-130) been filed? Yes No If yes, name of petitioner: ______________________________________________________ Filed under what category? (Extraordinary Ability, National Interest Waiver, Marriage based, etc.) ____________________________________________________________________________ Has the immigrant petition been approved? Yes No If yes, please provide the following:
Date (mm/dd/yyyy): _______________ Case Number: ____________________________ Have you filed for adjustment of status to Permanent Residency (I-485)? Yes No If yes, what was the date of filing? (mm/dd/yyyy): ____________________________________ Has it been approved? Yes No If yes, please provide the date of approval (mm/dd/yyyy): _________________________
Have you applied for your Employment Authorization Document (EAD) (I-765)? Yes No If yes, expiration date (mm/dd/yyyy): ____________________ Have you applied for Advance Parole (AP) (I-131)? Yes No If yes, expiration date (mm/dd/yyyy): ____________________ If no, do you have a valid H-1B visa stamp in your passport? Yes No If yes, expiration date (mm/dd/yyyy): ____________________
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NOTE: H-1B employees whose labor certification and/or immigrant petition have been pending for more than 365 days and are nearing the six year limit on H-1B, may be eligible to file for an extension of their H-1B status. Extensions may be filed in one year increments until such time that the permanent residency has been approved. Extensions may be filed in three year increments if the applicant is unable to apply for adjustment of status because of the per country visa number retrogression but the I-140 has been approved. If this applies to you, please provide a copy of the following, as applicable: I-140 or I-130 receipt and/or approval notice I-485 receipt and/or approval notice EAD: I-765 receipt and/or approval notice Advance Parole: I-131 receipt and/or approval notice
Additional Information
If there is additional information you feel we should be made aware of, please let us know below. For example, do you have a change of status petition already pending with USCIS, are you anticipating an upcoming marriage or birth/adoption of a child, have you held any other immigration status that was not listed in this form already (TN, E-3, Asylee, etc.)?
Signature
You must sign or the application will be incomplete. To verify that all of the information above is accurate and complete, please sign below: Print name: _________________________________________________________________________________ Signature: __________________________________________________________________________________ Date: _______________
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Beneficiary Checklist All applicants: (1 copy of each unless noted otherwise) Passport – biographical information page only (valid at least 6 months beyond start date of petition) Copy of diploma/certificate AND English translation* Copy of transcript (if your field of study is not indicated on diploma/certificate) AND English translation* Credential evaluation, if degree was earned abroad (except Canadians) – see note on page 4 regarding
ECFMG certification for foreign medical graduates Current Curriculum Vitae or Resume
If currently in the U.S.: Copy of the I-94 (now obtained online at www.cbp.gov/i94) Copy of the visa page from your passport
If you are currently in F-1 or F-2 status, please also include: Copies of all previous I-20(s) Copy of both sides of Employment Authorization Document (EAD), if on Optional Practical Training (OPT) If currently in F-2 status, submit copies of F-1’s I-94/visa/passport bio page
If you are currently or have ever been in J-1 or J-2 status, please also include: Copies of all IAP-66(s) or DS-2019(s), front and back If currently in J-2 status, submit copies of J-1’s I-94/visa/passport bio page If subject to the 2 year home residence requirement (212e), provide the following:
o U.S. Department of State No Objection Letter AND I-612 USCIS Approval Notice o OR, if you fulfilled the requirement, evidence you were in your home country for that time
If you have ever been in H-1B or H-4 status, please also include: Copies of all previous I-797 Approval Notice(s) Copy of paystubs from the past 4 months If you currently hold H-4 status, copies of documents related to spouse’s H-1B including: employment letter, last
4 months pay stubs, H-1B Approval Notice(s), I-94, visa stamp, passport If you have dependent(s) that are applying for H-4 status and are inside the U.S., please also include: Completed Form I-539 – must be signed in BLUE ink by dependent not the beneficiary Copies of all previous immigration documents (DS-2019, I-20 and/or I-797) Copies of the following for all dependent’s
o I-94 o Visa page from passport o passport biographical page (valid at least 6 months beyond start date of petition)
Copies of the following for a dependent spouse: o Marriage certificate AND English translation*
Copies of the following for dependent children: o Birth certificate(s) AND English translation*
$290 filing fee for I-539 (Personal check or money order from a U.S. bank payable to the “U.S. Department of Homeland Security”). This cannot be paid by your department.
*Translations If any documents are not in English, they must be translated. The beneficiary may not do the translating. The translation does NOT need to be done by a professional translator but it must contain the following statement. “I, (name), certify that I am competent to translate from the (name of language) language into English and that the attached is the accurate translation of the original documents.” The translation must also be signed and dated by the translator.