Name

First Name

Last Name

Home Number

Country

(###)

###

####

Work Number

Country

(###)

###

####

Fax Number

Country

(###)

###

####

Spouse's Name

First Name

Last Name

Is this your first marriage?

Yes

No

Has your spouse been marriage previously?

Yes

No

Have you ever applied for permanent residence?

Yes

No

Are you or is your spouse, child, mother or father, brother or sister a permanent resident of U.S. Citizen?

Yes

No

Have you ever had an issue with U.S. Customs and Border Protection (CBP)?

Yes

No

Have you ever been denied entry into the U.S.?

Yes

No

Have you ever had issues with law enforcement anywhere in the world?

Yes

No

has an immediate family member ever had issues with law enforcement?

Yes

No

Have you ever been arrested, detained, or convicted for/of a crime?

Yes

No

Have you ever been charged with a crime, but the case was not prosecuted or the case was dismissed?

Yes

No

I confirm that the foregoing is true. I further understand the information provided herein to the Law Office of Nevin F. Murchie, PLLC is necessary to review my legal options and that it will be kept in the strictest confidence.

Please check box to confirm.