into the United States was under the name of: (Last, First, 19) My first arrival to the United States was on:(Month, Day.
22) If admitted as a nonimmigrant, period for which
admitted: (Month, Day, Year)
20) Place or port of first arrival: (Place or Port, Ciry. and State)
23) My last extension of stay in the United States expired on: (Month, DUY. Year)
2 1) I: 0 was admitted as a lawful permanent resident.
0 was admitted as a nonimmigrant. Specify visa type:
Full Name and Address of Employer
0 entered without inspection.
Earnings Per Week
24) Since the date of my first arrival, I departed from and returned to the United States at the following places and on the following dates:
(Please list all departures regardless of how hriejly you were ahsentfi-om the United States)
ffyou have never departed from the United States since your original date of arrival, please mark an X in this box: 0
Port of Deparhlre (Plucc or Pon. Cify and Store)
Departure Date (Month. b y .
Port of Departure (Place or Pun, Cify und Stufe)
Departure Date (Month. Day, Yeur Purpose of Travel
------ ------------ -------
Admltled? 0 Yes 0 No
Return Date (Month. Duy. Year) Manner of Return
Port of Rehlrn (P~UCP
or Pod. City and Store)
25) Have you ever departed the United States:
a) under an order of deportation, exclusion or removal? -------- 0 Yes 0 NO
0 Yes 0 No
b) pursuant to a grant of voluntary departure? ....................
26) I am not married: 0 27) If married, the name of my spouse is: (Last, First, Middle)
28) Date of marriage: (Month. Day, Year)
Iammarried: 0 I
30) Birth place of spouse: (city and Countty)
I 29) The marriage took place in: (City and Countgg
3 1) My spouse currently resides at:
Apt. number und/ur in core OJ
Number und Sweet
City or Tdwn
32) Birth date of spouse: (Month, Day, Yeur)
34) If your spouse is other than a native born