EMPLOYEE’S GENERAL INFORMATION

Full Name (with last name in caps, First Name, and FULL middle name):

Current U.S. Address:

Address in your home country:

Home Phone Number:

Country of Citizenship:

City and Country of Birth:

Date of Birth (Mo/Day/Yr):

Current Visa Status: (H1B, L1, TN, etc.)

Alien Registration No: (A#) if applicable

I-94 card #:

Work Phone No:

Email Address:

Manager’s Name:

Manager’s Email:

Manager’s Phone #:

INFORMATION REGARDING THE PROPOSED JOB

Worksite (Please provide complete address):

Job Title:

Yearly salary:

Minimum Educational degree required for this position: (e.g., B.S., B.A. or M.S.):

Required field of studies (e.g., CS or EE):

Is Training required for this position? If yes, how many months of training required and the field of training:

Years of experience required for the position, if any (be realistic as excessive requirements may lead to delays and/or a denial of your case):

Alternative field of study acceptable (if any):

Alternative combination of education and experience accepted (if any):

Is a foreign educational equivalent acceptable?

Is experience in the alternative occupation acceptable? (e.g. will accept 4 years in CS in lieu of BS EE and 0 years of experience)

Provide a detailed job description for this position (the job should be described broadly as to encompass the position that you will hold as a permanent resident.  Do not base the job description on current short-term projects)

Number of Employees in area of intended employment:

Do you have an ownership interest or a familial relationship to the owners, stockholders, partners, or corporate officers of the business?

Does this position involve a combination of occupations? ( e.g. S/W and H/W, etc.)

Special Requirements.  List particular skills and or experience that this position requires, which enables one to perform the job duties adequately (e.g., particular programming languages, certification from Microsoft, Oracle, and etc.).  You can only list those skills you had attained prior to joining the sponsoring/current employer:

Name and addresses of Colleges and Universities attended (include trade or vocational training facilities but not high school):

Field of Study

From

Mo./Yr.

To

Mo./Yr.

Degrees or Certificates Received and Field of Study

CURRENT EMPLOYER

Name of current Employer:

Complete Address of Employer:

Type/Nature of Business:

Job Title:

Date Started (month & year):

Date ended (month & year):

Number of Hours Worked Per Week:

Describe in detail the duties performed, including the use of tools, machines or equipment:

PREVIOUS EMPLOYER

Name of the Employer:

Complete Address of Employer:

Type/Nature of Business:

Job Title:

Date Started (month & year):

Date ended (month & year):

Number of Hours Worked Per Week:

Describe in detail the duties performed, including the use of tools, machines or equipment:

PREVIOUS EMPLOYER

Name of the Employer:

Complete Address of Employer:

Type/Nature of Business:

Job Title:

Date Started (month & year):

Date ended (month & year):

Number of Hours Worked Per Week:

Describe in detail the duties performed, including the use of tools, machines or equipment:

PREVIOUS EMPLOYER

Name of the Employer:

Complete Address of Employer:

Type/Nature of Business

Job Title:

Date Started (month & year):

Date ended (month & year):

Number of Hours Worked Per Week:

Describe in detail the duties performed, including the use of tools, machines or equipment:

PREVIOUS EMPLOYER

Name of the Employer:

Complete Address of Employer:

Type/Nature of Business:

Job Title:

Date Started (month & year):

Date ended (month & year):

Number of Hours Worked Per Week:

Describe in detail the duties performed, including the use of tools, machines or equipment:

                                                                                             Spouse

Name:                                                                                                                                                                              

Address:                                                                                                                                                                         

Date & Place of birth:                                                                                                                                                     

                                                                                            Child # 1

Name:                                                                                                                                                                         

Address:                                                                                                                                                                    

Date & Place of birth:                                                                                                                                                 

                                                                                            Child # 2

Name:                                                                                                                                                                               

Address:                                                                                                                                                                          

Date & Place of birth:                                                                                                                                                         

                                                                                            Child # 3

Name:                                                                                                                                                                                   

Address:                                                                                                                                                                               

Date & Place of birth: