Clark Wilson LLP
U.S. Immigration Assessment Form

After completing the following form to the best of your ability, press the SUBMIT button to  send to Clark Wilson LLP. You may also print this form and fax or mail it to us. We will then contact you to arrange an appointment in person or by phone to review your information and advise you of your prospects for immigration to the United States and of the best method to achieve your goal. 

How did you learn about Clark Wilson LLP?
Friend/Relative  Agent  Advertisement
Lawyer Search Engine Link
Other, please specify: 

Objective

Briefly Describe how we can assist you:


Bio Data


Family Name: 
First Name:
Middle Name: 
Other Names Used:
Sex:  Male Female
Age: 
Date of Birth: (Day/Month/Year)
City & Country of Birth:
Social Security Number: 

 Marital Status:
Never Married Married Divorced Separated Widowed
Please Provide Spouse's full name:

* If married, have your spouse complete an additional Assessment Form.

 Address (both within and outside the United States):

Home TEL:  FAX:
Work TEL: E-mail: 
Country(ies) of Citizenship:

Please provide the full name, city and country of birth,
and birthdate of each of your children:


RELATIVES IN THE UNITED STATES:
Please list at least three of your
closest relatives in the United 
States (if any) and state their 
relationship to you, their 
immigration or citizen status, 
their address and phone number:



Visa & Passport
APPLICANT'S VISAS
Current Visa 
Held (Country):
Date Admitted:
Visa Expiry Date:
Previous Visa Held:
Date Admitted:
Visa Expiry Date:
Alien Registration Number:
I-94 Number:
I-94 Expiry Date:
Last Entry to U.S.:
(Place, Date, Name of Carrier)
APPLICANT'S PASSPORT
Issued By (Country):
Issue Date:
Expiry Date:
Passport Number:

Have you ever applied for Permanent Resident Status? Yes No


Grounds for Citizenship

YOU MAY ALREADY BE A CITIZEN

Do you have a parent or grandparent who was born in or is a citizen of the United States? Yes No

Are you an American Indian born in Canada having at least 50 per cent of American Blood? Yes No

DO YOU QUALIFY ON THE BASIS OF YOUR
OCCUPATIONAL SKILLS AND TRAINING

Have you located an employer in the United States who is willing to employ you? Yes No

List your present and previous employers starting with the most recent:
A. Present or Most Recent Employer
Name of Employer
Title/Position
Number of years worked
Description of duties
B. Previous Employer
Name of Employer
Title/Position
Number of years worked
Description of duties
C. Previous Employer
Name of Employer
Title/Position
Number of years worked
Description of duties


Education

INDICATE THE LEVEL OF EDUCATION COMPLETED:
years Primary/Elementary
years Secondary/High School
years of Vocational Commercial Technical Training
years of University College Other

Please provide details of any other training or education:


Please list all degrees and diplomas obtained from educational institutions:

What languages do you speak or write:


Is there anything else that you believe may be relevant to your application?
Please include any questions or comments you may have.


Grounds for Exclusion
Have you or any family member ever made a fraudulent statement or 
misrepresented a fact to obtain or try to obtain any immigration benefit 
from the U.S?
YES NO
Have you ever been afflicted with a communicable disease of public 
health significance, a dangerous physical or mental disorder, or been 
a drug abuser or addict? 		 YES NO
Have you ever been arrested or convicted for any offense or crime, 
even through subject of pardon, amnesty, or other such legal action?		 YES NO
Have you ever been a controlled substance (drug) trafficker? YES NO
Have you ever been a prostitute or procurer of prostitutes? YES NO
Were you excluded or deported from the United States within the 
last 20 years?		 YES NO
Do you seek to enter the United States to engage in export control 
violations, subversive or terrorist activities or any unlawful purpose?		 YES NO
Have you ever ordered, incited, assisted, or otherwise participated in 
the persecution of any person because of race, religion, national origin, 
or political opinion under the control, direct or indirect, of the Nazi 
Government of Germany, or of the government of any areas occupied 
by, or allied with, the Nazi Government of Germany, or have you ever 
participated in genocide?		 YES NO


PLEASE READ THE FOLLOWING STATEMENTS AND INDICATE YOUR
ACCEPTANCE OF THESE TERMS PRIOR TO SUBMITTING THIS FORM
 I have prepared the answers to these questions and to the best of my ability I believe them to be truthful and correct. 
I understand that the submission of this form does not create any obligation for myself or for the lawyer with whom I wish to request a formal consultation. I further understand that submission of this form does not create an attorney-client relationship and that the lawyer is not obliged to schedule a consultation with me.


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