Microsoft Word - Questionnaire Client

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1 English 中文 Employment-creation immigrant visa and permanent residence questionnaire. Please complete all of the following information in English or Chinese for each person in the family who seeks to immigrate to the United States. 创造就业机会移民签证和永久居留问卷表请以英文或中文填写希望移民美国的每名家庭成员的全部下述信息 : 1. Family name 1. 姓 2. First name 2. 名 3. Middle name, if any 3. 中间名 ( 如有 ) 4. Other names used (maiden name, alias, etc.) 4. 曾用名 ( 女子婚前姓名化名等 ) 5. Date of birth (mm-dd-yyyy) 5. 出生日 :( 月 - 日 - 年 ) 6. Age 6. 年龄 7. City of birth 7. 出生城市 8. Province of birth 8. 出生省份 9. Country of birth 9. 出生国 10. Nationality 10. 国籍 11. Gender (check one) Male Female 12. Marital status (check one) Single (never married) 11. 性别 ( 划勾 ) 男女 12. 婚姻状况 ( 划勾 ) 单身 ( 未婚 ) PDF processed with CutePDF evaluation edition

2 Married Widowed Divorced Separated 13. Number of times married, including present marriage, if any 已婚丧偶离婚分居 13. 结婚次数 ( 包括当前婚姻 )( 如有 ) 14. Permanent address in the United States where you intend to live, if known, and name of person who currently lives there, if any 14. 拟在美国生活的永久地址 ( 如已知 ), 以及目前生活在该地的人的姓名 ( 如有 ) 15. Telephone number in the United States, if any 15. 美国的电话号码 ( 如有 ) 16. Present occupation 16. 现有职业 17. Residence address in PRC 17. 中国居住地址 18. Residence telephone number in PRC 18. 中国住宅电话号码 19. Work telephone number in PRC 19. 中国工作电话号码 20. Family or maiden name of spouse 20. 配偶家庭姓氏或婚前姓氏 21. First name of spouse 21. 配偶名字 22. Middle name of spouse, if any 22. 配偶中间名 ( 如有 ) 23. Date of birth of spouse 23. 配偶出生日 24. Place of birth of spouse (city, province, country) 25. Residence address of spouse, if different from your own) 24. 配偶出生地 ( 国家省市 ) 25. 配偶住址 ( 如与你的不同 ) 26. Occupation of spouse 26. 配偶职业 Page 2

3 27. Date of marriage (mm-dd-yyyy) 27. 结婚日期 ( 月 - 日 - 年 ) 28. Father's family name 28. 父姓 29. Father's first name 29. 父名 30. Father's middle name, if any 30. 父亲中间名 ( 如有 ) 31. Father's date of birth (mm-dd-yyyy) 31. 父亲出生日 ( 月 - 日 - 年 ) 32. Father's residence address 32. 父亲住址 33. If father is deceased, year of death 33. 如父亲已去世, 列明去世年份 34. Mother's family name 34. 母姓 35. Mother's first name 35. 母名 36. Mother's middle name, if any 36. 母亲中间名 ( 如有 ) 37. Mother's date of birth (mm-dd-yyyy) 37. 母亲出生日 ( 月 - 日 - 年 ) 38. Mother's residence address 38. 母亲住址 39. If mother is deceased, year of death 39. 如母亲去世, 列明去世年份 40. Attach a list of the names, dates and places of birth, and residence address of all children 40. 附上列明所有子女的姓名出生日出生地住址的清单 41. Attach a list of all places you have lived for at least six months since reaching the age of 16. Begin with your present residence address and include the dates when you started and stopped living at each address 42. Attach a list of the names of the spouse and any children who will immigrate with you to the US at the same time 41. 附上你 16 岁后生活过至少六个月的所有地方先列明你的现有住址列出在每一地点的生活起迄日期 42. 附上将随同你同时移民美国的配偶和任何子女的名单 43. Attach a list of the names of the spouse 43. 附上之后将随同你移民美国的配偶和 Page 3

4 and any children who will immigrate with you to the US later 44. Attach a list of all employment for the last ten years, including the employer's name, address, your job title and the dates when you started and stopped working at each employer 任何子女的名单 44. 附一清单列明过去十年的工作, 包括雇主名称地址你的职务, 以及在每一个雇主的工作起迄日期 45. Attach a list of all educational institutions attended, including the name, address, course of study, degree or diploma awarded, and the dates you started and stopped studying at each institution 45. 附上列明你上过的所有学校的清单, 列出学校名称地址专业学位或文凭以及在每所学校的学习起迄日期 46. List all languages spoke or read 46. 列明你会 ( 口头或书面 ) 的所有语言 47. Attach a list of all professional associations to which you belong 48. Were you previously in the Military 49. If you were previously in the military, state your branch of service 50. If you were previously in the military, state your rank or position 51. If you were previously in the military, state your military specialty or occupation 52. If you were previously in the military, state the dates that you started and stopped (mm-dd-yyyy) 53. Attach a list of all previous visits or residence in the US (if never, write never ). Include the date you started and stopped visiting the US (mm-dd-yyyy), location, type of visa, and alien registration 47. 附上列出你加入的所有职业协会 48. 你参过军吗? 49. 如果参过军, 列出服役部门 50. 如参过军, 列明你的军衔或职位 51. 如参过军, 列明你的军事专业或职业 52. 如参过军, 列明你参军的起迄日期 ( 月 - 日 - 年 ) 53. 附上列出你先前的所有美国之行或在美国居留经历 ( 如无, 则写无 ) 列明美国之行的的起迄日期 ( 月 - 日 - 年 ) 地址签证类型, 以及外国人登记号 Page 4

5 number, if any ( 如有 ) 54. Are you someone with a communicable disease of public health significance; who has failed to present documentation of having received vaccinations in accordance with U.S. law; who has or has had a physical or mental disorder that poses or is likely to pose a threat to the safety or welfare of the alien or others; or who is a drug abuser or addict. 55. Are you someone convicted of, or who admits having committed, a crime involving moral turpitude or violation of any law relating to a controlled substance or who is the spouse, son or daughter of such a trafficker who knowingly has benefited from the trafficking activities in the past five years; who has been convicted of 2 or more offenses for which the aggregate sentences were 5 years or more; who is coming to the United States to engage in prostitution or commercialized vice or who has engaged in prostitution or procuring within the past 10 years; who is or has been an illicit trafficker in any controlled substance; who has committed a serious criminal offense in the United States and who has asserted immunity from prosecution; who, while serving as a foreign government official and within the previous 24-month period, was responsible for or directly carried out particularly severe violations of religious freedom; or whom the President has identified as a person who plays a significant role in a severe form of trafficking in persons, who otherwise has knowingly aided, abetted, assisted or colluded with such a trafficker in severe forms of trafficking in persons, or who is the 54. 你是影响公共健康的传染病患者吗? 你是未能提交证明已按美国法律要求接种疫苗的文件者吗? 你是或曾是对外国人或其他人的安全和福利构成威胁或可能构成威胁的生理或心理疾病患者吗? 是吸毒者或毒瘾者吗? 55. 你被判定犯有或承认犯有涉及道德败坏或违反管制物质法的罪行? 你是在知情的情况下从过去 5 年中的管制物质贩卖活动中获益的贩卖者的配偶或子女吗? 你被判犯有两项或两项以上罪名刑期总计达 5 年或 5 年以上 ; 你是来美国从事卖淫或商业化不道德行为或过去 10 年中曾从事卖淫或拉皮条服务 ; 你是或曾是任何管制物质的非法贩卖者? 你在美国曾犯有重罪但主张免予公诉? 你在担任外国政府官员时, 在过去 24 个月内, 曾负责或直接实施极其严重的侵害宗教自由的行为 ; 你是美国总统指名的在严重贩卖人口活动中扮演重要角色的人, 或者在知情的情况下帮助教唆协助严重贩卖人口活动的贩卖者或与其串通, 或是过去 5 年内在知情的情况下受益于贩卖人口活动的该等贩卖人口者的配偶或子女? Page 5

6 spouse, son or daughter of such a trafficker who knowingly has benefited from the trafficking activities within the past five years. 56. Are you someone who seeks to enter the United States to engage in espionage, sabotage, export control violations, terrorist activities, the overthrow of the Government of the United States or other unlawful activity; who is a member of or affiliated with the Communist or other totalitarian party; who participated in Nazi persecutions or genocide; who has engaged in genocide; or who is a member or representative of a terrorist organization as currently designated by the U.S. Secretary of State. 56. 你是想进入美国从事间谍活动破坏活动违反出口管制活动恐怖活动推翻美国政府或其他非法活动 ; 你是共产党或其他集权主义政党的党员或与其有附属关系 ; 你参与了纳粹的迫害活动或种族大屠杀活动 ; 你参与了种族大屠杀 ; 你是目前被美国国务卿列名的恐怖组织的成员或代表 57. Are you likely to become a public charge. 57. 你可能成为受政府救济者 58. Are you someone who seeks to enter for 58. 你想进入美国从事技术工种或非技术 the purpose of performing skilled or 工种但未经劳工部长认证 ; 你是外国医 unskilled labor who has not been certified 学院毕业生, 想提供医疗服务, 但未通 by the Secretary of Labor; who is a graduate 过美国全国医学考试委员会考试或对等 of a foreign medical school seeking to perform medical services who has not 考试 ; 或你是医疗保健工作者, 想从事 passed the NBME exam or its equivalent; or 该等工作, 但没有美国外国护校毕业生 who is a health care worker seeking to 考试委员会或对等的经批准的独立认证 perform such work without a certificate 组织颁发的证书 from the CGFNS or from an equivalent approved independent credentialing organization. 59. Are you someone who failed to attend a hearing on deportation or inadmissibility within the last 5 years; who seeks or has 59. 你过去五年里曾缺席遣返或拒绝入境听证 ; 你试图或曾试图通过欺诈或虚假陈述获得签证进入美国或任何移民好 Page 6

7 sought a visa, entry into the United States, or any immigration benefit by fraud or misrepresentation; who knowingly assisted any other alien to enter or try to enter the United States in violation of law; who, after November 30, 1996, attended in student (F) visa status a U.S. public elementary school or who attended a U.S. public secondary school without reimbursing the school; or who is subject to a civil penalty under INA 274C. 60. Are you someone who is permanently ineligible for U.S. citizenship; or who departed the United States to evade military service in time of war. 61. Are you someone who was previously ordered removed within the last 5 years or ordered removed a second time within the last 20 years; who was previously unlawfully present and ordered removed within the last 10 years or ordered removed a second time within the last 20 years; who was convicted of an aggravated felony and ordered removed; who was previously unlawfully present in the United States for more than 180 days but less than one year who voluntarilydeparted within the last 3 years; or who was unlawfully present for more than one year or an aggregate of one year within the last 10 years. 处 ; 你在知情的情况下协助任何其他外国人非法进入或企图非法进入美国 ; 你在 1996 年 11 月 30 日后以学生签证 (F) 身份在美国公立小学上学, 或在美国公立中学上学, 而未向学校偿还费用 ; 或你受到移民和国籍法第 274( 条 ) 项下的民事处罚 60. 你永久无权享有美国公民身份 ; 你在战争期间离开美国以逃避兵役 61. 你在过去五年中被强行遣送或过去 20 年中被第二次强行遣送 ; 你在过去 10 年中曾非法居留并被强行遣送 ; 你被判定犯有严重重罪并被强行遣送 ; 你之前在美国非法居留超过 180 天但不到 1 年, 但在过去三年中自愿离境 ; 或你在过去 10 年中非法居留一年以上或总计非法居留一年以上 62. Are you someone who is coming to the United States to practice polygamy; who withholds custody of a U.S. citizen child outside the United States from a person granted legal custody by a U.S. court or 62. 你来到美国旨在搞一夫多妻 ; 你拒绝给予美国法院授予其合法监护权的人对美国境外的美国儿童的监护权, 或故意协助他人如此行事 ; 你违反任何法律法规在美国投票 ; 或放弃美国国籍以逃 Page 7

8 intentionally assists another person to do so; who has voted in the United States in violation of any law or regulation; or who renounced U.S. citizenship to avoid taxation. 税 63. Are you someone who is a former 63. 你过去曾是未履行 2 年外国居留要求 exchange visitor who has not fulfilled the 2- 的交流访问者 year foreign residence requirement. 64. Have you been determined by the 64. 你被美国司法部长认定为属于故意提 Attorney General to have knowingly made a 出无意义的避难申请者 frivolous application for asylum. 65. Are you someone who has ordered, carried out or materially assisted in extrajudicial and political killings and other acts of violence against the Haitian people; who has directly or indirectly assisted or supported any of the groups in Colombia known as FARC, ELN, or AUC; who through abuse of a governmental or political position has converted for personal gain, confiscated or expropriated property in Cuba, a claim to which is owned by a national of the United States, has trafficked in such property or has been complicit in such conversion, has committed similar acts in another country, or is the spouse, minor child or agent of an alien who has committed such acts; who has been directly involved in the establishment or enforcement of population controls forcing a woman to undergo an abortion against her free choice or a man or a woman to undergo sterilization against his or her free choice; or who has disclosed or trafficked in confidential U.S. business information 65. 你曾下令执行或大力协助对海地人民的不经司法程序进行的屠杀政治性屠杀和其他暴力行为 ; 你曾直接或间接地协助或支持哥伦比亚的 FARC ELN 或 AUC 中的任一组织 ; 你滥用政府或政治职务, 将古巴境内被没收或征用的财产占为已有 ( 美国国民对该等财产主张权利 ); 你贩卖该等财产或是该等贪污的共谋, 或在其他国家犯有类似行为, 或者是犯有该等行为的外国人的配偶未成年子女或代理人 ; 你曾直接参与制定或执行人口控制政策, 强迫妇女违背其自由意愿实施流产, 或强迫男人或女人违背其自由意愿实施绝育手术 ; 或你曾披露或走私获得的与美国参与化学武器公约有关的保密美国业务信息, 或是该等人士的配偶未成年子女或代理人 Page 8

9 obtained in connection with U.S. participation in the Chemical Weapons Convention or is the spouse, minor child or agent of such a person. 66. Have you ever been charged, arrested or 66. 你曾被指控被逮捕或被判犯有任何 convicted of any offense or crime 罪行 ( 如是, 请附上说明 ) (If answer is Yes, please attach an explanation) 67. Have you ever been refused admission to the United States at a port-of-entry (If answer is Yes, please attach an explanation) 68. Have you ever applied for a US social security number and, if so, what is your number Number: 67. 你曾在某一入境港被拒绝进入美国 ( 如是, 请附说明 ) 68. 你曾申请过美国社会保障号? 如是, 请说明号码号码 : Page 9

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(Adobe Heiti Standard OpenType Regular Adobe GB1 5) 1/7 页 2013/01/18 美国签证申请表 DS-160 用提问表格 * 提问表格填写以後要护照照片页复印件和有延长的话页面也要复印件外国人登録証或在留卡 ( 正反面复印件 ) 彩色照片 1 张 ( 请注意照片的要求 ) 有取得过美国签证的人, 签