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Questionnaire for the Visa Screen Certificate
Please state your full name: _________________________________________________
Please state your CGFNS Identification Number: __________________________________
1. Pre-Professional/Other Education:
List information for each school attended whether completed or not, beginning with the first
year of your secondary school education and ending with the last year of non-professional
education. (Enclose a photocopy of your diploma, certificate, or external exam certificate from your
secondary school and non-professional post-secondary school, including a word-for-word English
translation of each of these documents. If unable to provide your secondary school diploma or
external exam certificate, the school or external agency must submit directly to ICHP your exam
results or verification of graduation date and level of education completed).
Name of Non- City, Month/Year Month/Year Name of Diploma
Professional State/Province Entered Completed/Graduated /Certificate in its
Schools Attended & Country Original Language
Secondary:
Post-secondary non-
professional
programs:
2. Professional Education:
Please List information for each school attended, whether completed or not. Complete a
“Request for Academic Records Form.” Forward a “Request for Academic Records Form”
along with one marked envelope “Transcripts” to each school listed below. The school will be
required to forward the completed “Request for Academic Records Form” and your academic
record directly to ICHP.
Name of City, Professional Month/Year Month/Year Name of
Professional State/Province, Title Entered Completed/Graduated Diploma or
Schools Country Obtained Certificate in
Attended its Original
Language
3. Registration/License:
Complete and forward a “Request For Validation of Registration/License Form” along with
one enclosed envelope marked “Validations” to every registration/licensing authority
responsible for issuing/validating your license(s)/registration(s) in your country of education
and in the country (ies) where you hold licenses. The registration/licensing authorities will be
required to forward “Request For Validation of Registration/License Form” directly to ICHP.
ICHP must have a validation for every license held in the past and present. If the diploma
authorizes practices in country of birth, forward this form to the institution that issued it
(school, Ministry of Health, etc.) (At least one of the licenses must be current at the time the
Visa Screen Certificate is issued).
Nurses Only
1. Provide the title of your registration/license in your country of education: _________________
2. If your country does not issue a license, does your diploma give you the right to practice?
□ Yes □ No
3. Indicate the TITLE of your CURRENT registration/license: _______________________________
4. In which country or countries are you currently licensed?__________________________________
5. If licensed in the United States, please list states: ________________________________________
6. If licensed in Canada, please list provinces:_____________________________________________
Non-Nursing Healthcare Professionals
1. Does your country of education require license for your profession? □ Yes □ No
2. Have you ever been licensed in your country of education? □ Yes □ No
3. Are you licensed in the United States? □ Yes □ No
4. If yes, are you licensed with a State or National registration authority? □ State □ National
Please name the State or States you are licensed in? _____________________________
Please name the National registration authority you are licensed with:___________________.
5. Are you licensed in Canada? □ Yes □ No
If yes, are you licensed with a Provincial or National registration authority? □ Provincial □ National
Please name the Province or Provinces you are licensed in? _____________________________
Please name the National registration authority you are licensed with:___________________.
4. English Language Proficiency
Non-exempt applicants must submit English Language proficiency score from either
Educational Testing Service (ETS) [Test of English as a Foreign Language (TOEFL), Test of
English for International Communication (TOEIC), Test of Written English (TWE), and Test
of Spoken English (TSE)] or IELTS, Inc. Your test results must be forwarded directly to ICHP
by ETS or the Cambridge Examinations and IELTS International. (The Visa Screen
Application may be submitted prior to registration for the English Language proficiency
examinations).
ETS Administrative Dates:
TOEFL Date of Test: _____________ (Month/Day/Year)
Registration/Appointment Number:________________.
TOEIC Date of Test: _____________ (Month/Day/Year)
Registration/Appointment Number:________________.
TWE Date of Test: _____________ (Month/Day/Year)
Registration/Appointment Number:________________.
TSE Date of Test: _____________ (Month/Day/Year)
Registration/Appointment Number:________________.
IELTS Administrative Dates:
Date of Test: _____________ (Month/Day/Year)
Test/Form Number:________________.
Questionnaire for I-140 Application
1. Complete address in India ___________________________________________
2. Complete address in India (hand written) in the Indian alphabets
________________________________________________________________________
____________________________________________________________
__________________________ (Please keep in mind that this hand written information
will be copied by the immigration paralegal, so kindly write in bold clear script).
3. Full Name in Indian alphabets (hand written)
________________________________________________________________________
________________________________________________________________________
______________ (Please keep in mind that this hand written information will be copied
by the immigration paralegal, so kindly write in bold clear script).
4. Daytime Phone Number in India _____________________________
5. Email ID _____________________________
6. If married, Full name of husband ____________________________________
7. Date of Birth of the husband _________________________________
8. Country of Birth of the husband ____________________________________
Full names of children, their gender, with the dates of their birth, and countries of birth
___________________________________________________________________________
___________________________________________________________________________
_____________________________________
APPLICATION FOR IMMIGRANT VISA AND ALIEN REGISTRATION
1. Family Name _________________________
2. First Name ___________________________
3. Middle Name _________________________
4. Other Names used or Aliases _________________________
5. Please write your full name in your native alphabet (this should be handwritten in bold
letters so as to avoid any confusion)
__________________________________________________________________
6. Date of Birth ____________________
7. Age _____________________
8. Place of Birth ______________________________________________________
City Province/State Country
9. Marital Status ______________________________________
10. Your Present Occupation _____________________________
11. Present Address ____________________________________
12. Name of Spouse ____________________________________________________
First Name Middle Name Family Name
13. Address of Spouse (if different from your own)
________________________________________________________________________
____________________________________________________________
14. Date of Marriage ________________________
15. Your Father’s Name _________________________________________________
First Name Middle Name Family Name
16. Father’s Date of Birth ________________________________
17. Father’s Place of Birth ________________________________
18. Father’s Current Address ______________________________
19. Father, if deceased, please give year of death ________________________
20. Your Mother’s Name ________________________________________________
First Name Middle Name Family Name
21. Mother’s Date of Birth ________________________________
22. Mother’s Place of Birth ________________________________
23. Mother’s Current Address ______________________________
24. Mother, if deceased, please give year of death ________________________
25. List Name, Dates & Places of Birth, and Addresses of all children
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
______________________________
26. List below all places you have lived for at least six months since reaching the age of 16.
City or Town Province Country From/To (mm-yyyy)
______________ ________________ ______________ __________________
______________ ________________ ______________ __________________
______________ ________________ ______________ __________________
______________ ________________ ______________ __________________
______________ ________________ ______________ __________________
27. List below all employment for the last ten years.
Employer Location Job Title From/To (mm-yyyy)
______________ ________________ ______________ __________________
______________ ________________ ______________ __________________
______________ ________________ ______________ __________________
______________ ________________ ______________ __________________
28. List below all educational institutions attended.
School & Location From/To (mm-yyyy) Course of Study Degree
______________ ________________ ______________ __________________
______________ ________________ ______________ __________________
______________ ________________ ______________ __________________
______________ ________________ ______________ __________________
29. Previous Military Service ________________ (Yes/No --- If applicable)
a) Branch of Military ____________________
b) Rank/Position ________________________
c) Dates of Service _________________________
d) Military Specialty/Occupation_____________________
30. List dates of all previous visits to or residence in the United States (if applicable)
From/To (mm-yyyy) Location Type of Visa “A” No. (If any)
______________ ________________ ______________ __________________
______________ ________________ ______________ __________________
______________ ________________ ______________ __________________
31. Please sign your name ___________________________________
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