Additional Information

EMPLOYEE Family Name Given Name Middle Name Birthdate: Country of Birth & Citizenship: Social Security Number: Current nonimmigrant status (F or H, etc:) Expiration date of current status: U.S. entry dates in each status:

SPOUSE

CHILD

U.S. exit dates in each status:

Most recent US arrival date and in what status:

I-94 Number: Expiration date of I-94: On OPT status?: Valid dates of OPT (provide copy of EAD and I-20 form) Foreign Address:

Passport Number: Date of issue: Expiration date:

Additional Information

e-Mail address: Current Street Address:

Emergency Contact: Daytime contact number: Evening contact number: