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P E R S O N A L I N F O R M ATI O N
QUESTIONNAIRE
To be completed by the beneficiary employee for whom the status or extension of stay is sought.
Please provide all the information requested below. Should you have any questions regarding the information
requested feel free to contact Assistant General Counsel Jigisha Patel at (617) 373-7073. Please return the
completed personal information questionnaire along with your documents to your
department/college administrator for processing.
Date Questionnaire completed: _____________________________________________________
INFORMATION ABOUT BENEFICIARY EMPLOYEE
1) Your FULL legal name: First ___________________________ Middle_____________________
Last___________________________________
Any other names by which you have been known _______________________________
2) Your place of birth: Town/City: ____________________ Province: ______________________
Country: _______________________________
3) Country of Citizenship: __________________________________
If naturalized, date of Naturalization: _______________________
4) Your date of birth: Month: _____________ Day: _________ Year: __________
5) Current Primary Contact Information (either in the U.S. or abroad if not living in U.S.):
Phone number: _______________ E-mail address: ________________
Address: ______________________________________________
_____________________________________________________
_____________________________________________________
6) Permanent Foreign Contact Information:
Phone number: _________________
Address: ______________________________________________
_____________________________________________________
_____________________________________________________
Revised September 2012
Is this address also to be used as your mailing address while outside of the US: _____Yes _____No
7) Current immigration status: F-1/OPT_____ TN _____ H1B_____ J-1/2_____ O-1_____
Other: _________________________________________________________________
None: Not in the U. S., or will be processing outside of the U.S., or will not be in the U.S. at the
time of filing _______________
IF YOU ARE NOT IN THE U.S., Location of Consulate or Port of Entry where you will apply for
your visa:
City______________________ Country ________________________
8) Date that status expires: ___________________________________________________
*Note: If you are currently in H-1B status, please include the last 4 months of your payroll
records and provide updated payroll records until the H-1B petition is field.
9) Have you ever been in J status? _______ yes _________ no
If “yes”, were you subject to the two year return to home country provision? ______ yes ______no
If “yes”, have you secured a waiver or served the two years in your home country? ____ yes ____no
10) Additional information needed of U.S. immigration history:
a) If you have ever held F or J visa status, list the dates and your SEVIS number(s): ___________
________________________________________________________________________
b) If you have ever applied for or been granted an Employment Authorization Document (EAD), list
your receipt number(s) beginning with three letters and provide copies of your EAD cards:
________________________________________________________________________
__________________________________________ ______________________________
11) Social Security Number (if applicable): _____________________________________
12) Alien Registration Number or “A Number” (if applicable): A____________________
13) Date and place of last entry/arrival into the U.S.:
Date: _____________________________________
Place: _____________________________________
14) Passport number: _____________________________ Date issued: ______________________
15) Expiration date of current passport: _____________________________________________
16) Number from most recent I-94: ________________________________________________
17) Name and address of current employer:
___________________________________________________________________________
___________________________________________________________________________
Revised September 2012
18) Date you plan to end employment with that company: _______________________________
*Note: If you are currently holding H-1B status, please do not end your employment without
speaking with Jigisha Patel at Office of the General Counsel, 617-373-7073.
19) Have you or has anyone else filed a petition or application for permanent residency on your behalf?
______ yes ________ no
20) Has any non-immigrant or immigrant petition filed on your behalf ever been denied?
______ yes ________ no If yes, please provide details and receipt number:
_______________________________________________________________________
21) Please list below any upcoming travel and notify University Counsel of any changes to travel
plans after completing this questionnaire and while this petition is pending. This is important as
traveling outside of the U.S. while your petition is pending may result in the petition being
deemed abandoned.
____________________________________________________________________________
______________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
INFORMATION ABOUT YOUR SPOUSE AND CHILDREN:
A. Full name of spouse: First__________________ Middle___________ Last__________________
B. Spouse’s birth place: Town/City, Province, and Country __________________________________
C. Country of Citizenship: ___________________________________________________
D. Spouse’s date of birth: Month __________ Day_______ Year_________
E. Spouse’s current immigration status: __________________
F. Date of expiration: _____________________
G. Spouse’s Alien Registration Number or “A Number” (if applicable): A____________________
H. If your spouse has ever been in H-1B status or H-4 status, please indicate all periods that he/she has
been in that status: __________________________________________________________
I. Is your spouse’s or child’s immigration status dependent upon yours?
______ yes ______no
NOTE: If “yes” and you and your family are currently in the United States, your spouse
(and any dependent children) must complete and submit to the Office of the General
Counsel USCIS Form I-539 to accompany the University’s petition on your behalf. The
immigration Form I-539 Application to Extend/Change Nonimmigrant Status is
Revised September 2012
available at: www.uscis.gov.
The immigration form must be accompanied by a check in the amount of $290 made
payable to “U.S. Citizenship and Immigration Services.”
INFORMATION ABOUT YOUR CHILDREN:
A. Child’s Name: ______________________________________ Date of Birth: ________________
Place of Birth: ______________________________________ Citizenship: __________________
B. Child’s Name: ______________________________________ Date of Birth: ________________
Place of Birth: ______________________________________ Citizenship: __________________
C. Child’s Name: ______________________________________ Date of Birth: ________________
Place of Birth: ______________________________________ Citizenship: __________________
NOTE: You only need one Form I-539 for your dependents. If you are filing for just your spouse,
or your spouse and children, or just your children, all can be included on the same form and the
filing fee is a single $290.
YOUR EDUCATION HISTORY IN THE UNITED STATES AND ABROAD:
Name & Address of School: (most recent first)
______________________________________________________________________________
______________________________________________________________________________
Dates of Study: From _____________ To _____________
Visa Status held if in U.S.: ___________________________
Name & Address of School:
______________________________________________________________________________
______________________________________________________________________________
Dates of Study: From _____________ To _____________ Visa Status held: ___________
Name & Address of School:
______________________________________________________________________________
______________________________________________________________________________
Dates of Study: From _____________ To _____________ Visa Status held: ___________
Revised September 2012
YOUR EMPLOYMENT HISTORY IN THE UNITED STATES AND ABROAD:
Name and Address of Employer: (current or most recent first)
______________________________________________________________________________
______________________________________________________________________________
Official Title of Position Held: _____________________________________
Beginning date (mm/dd/yyyy):_____________ End date (mm/dd/yyyy):_______________
Visa Status Held if in the U.S.: _________________________________________
Name and Address of Employer:
______________________________________________________________________________
______________________________________________________________________________
Official Title of Position Held: _____________________________________
Beginning date (mm/dd/yyyy):_____________ End date (mm/dd/yyyy):_______________
Visa Status Held if in the U.S.: _________________________________________
Name and Address of Employer:
______________________________________________________________________________
______________________________________________________________________________
Official Title of Position Held: _____________________________________
Beginning date (mm/dd/yyyy):_____________ End date (mm/dd/yyyy):_______________
Visa Status Held if in the U.S.: _________________________________________
Name and Address of Employer:
______________________________________________________________________________
______________________________________________________________________________
Official Title of Position Held: _____________________________________
Beginning date (mm/dd/yyyy):_____________ End date (mm/dd/yyyy):_______________
Visa Status Held if in the U.S.: _________________________________________
Revised September 2012
DOCUMENT CHECKLIST FOR BENEFICIARY EMPLOYEE
PLEASE PROVIDE THE FOLLOWING DOCUMENTS:
For yourself: _____ copy of passport ID page and all stamped pages from your current passport
_____ copy of your most recent I-94 Arrival-Departure Record
_____ copies of any and all prior immigration status documents (for example: SEVIS
Forms I-20 for F student status; SEVIS Forms DS-2019 for J status; Form I-797
approval notices for H-1B, O-1, etc.
_____ copies of any current or expired Employment Authorization Documents (EAD
cards)
_____ if currently in H-1B status, provide copies of past 4 months of payroll records from
current employer, and provide updated payroll records until the H-1B petition is
filed.
_____ if currently working in the U.S. in a visa status outside of Northeastern, please
provide an employment verification letter after speaking with Jigisha Patel in
University Counsel
_____ copies of all degree certificates/diplomas AND transcripts for all degrees
awarded with English translations if necessary.
_____ current resume or curricula vitae listing all employment
For your spouse (only if dependent on your status and filing form I-539 in the U.S.):
_____ copy of marriage certificate (with English translation if necessary)
_____ copy of passport ID page and all stamped pages from current passport
_____ copy of most recent I-94 Arrival-Departure Record
_____ copies of any and all prior immigration status documents
_____ completed Form I-539 Application to Extend/Change Nonimmigrant Status
by spouse and a check for $290 for the filing fee made payable to “U. S.
Citizenship and Immigration Services” (spouse must sign Form I-539)
For your children (for any and all children who are not U.S. Citizens, are dependent on your status and who
are filing form I-539 in the U.S.):
_____ copy of birth certificate (with English translation if necessary)
_____ copy of all stamped pages from current passport
_____ copy of most recent I-94 Arrival-Departure Record
_____ copies of any and all prior immigration status documents
Revised September 2012
_____ if you are not filing for your spouse but are including your children on your
petition, provide a completed Form I-539 and a check for $290 for your
children
Revised September 2012
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