To Be Completed by the Beneficiary Employee for Whom the Status Or Extension of Stay Is

P E R S O N A L I N F O R M AT I O N Q U E S T I O N N A I R E

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: ______

1 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: ______2 ______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 Office of the General 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

3 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: ______4 ______

Dates of Study: From ______To ______Visa Status held: ______

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: ______

Name and Address of Employer: ______5 Official Title of Position Held: ______

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 curriculum 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. Department of Homeland Security” (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)

6 _____ 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 _____ 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