ࡱ> a bjbj .xEbxEbL1%0 0 8tlTw_l ,'"N'N'N') a6%=d]]]]]]]$o`%cT]5Lg)^)LL]N'N'1_\\\LN'N']\L]\\\N'x/clM\]G_0w_\ycN( yc\yc\@D\F H@@@]][@@@w_LLLLyc@@@@@@@@@0 B r:  International Student Services PRELIMINARY DATA FORM Rev. 05/19 To be completed by foreign national seeking H-1B visa Please TYPE or PRINT clearly Personal Data Your full name  FORMTEXT        FORMTEXT        FORMTEXT       (As it appears in your passport) Family/Surname/Last Given/First Middle All other names used (include maiden name and names from all previous marriages)  FORMTEXT       Date of Birth Place of Birth  FORMTEXT        FORMTEXT        FORMTEXT       Month/Day/Year City State/Province Country Check one:  FORMCHECKBOX  Male  FORMCHECKBOX  Female Check one:  FORMCHECKBOX  Single  FORMCHECKBOX  Married  FORMCHECKBOX  Divorced Citizenship Country  FORMTEXT       Legal permanent residence country  FORMTEXT       (Attach proof of such residence if not your citizenship) U.S. Social Security Number (if any)  FORMTEXT       A# (if any)  FORMTEXT       Passport Number  FORMTEXT       Issue Date  FORMTEXT       Expiration Date  FORMTEXT       Position in home country  FORMTEXT       Check appropriate category:  FORMCHECKBOX  Professor/Teacher  FORMCHECKBOX  Graduate Student  FORMCHECKBOX  Researcher  FORMCHECKBOX  Physician  FORMCHECKBOX  Other (please specify)  FORMTEXT       Academic degrees and years awarded  FORMTEXT       Current mailing address  FORMTEXT        FORMTEXT       Home phone  FORMTEXT       Office phone:  FORMTEXT       Cell phone:  FORMTEXT       Fax number  FORMTEXT       Email  FORMTEXT       Permanent address outside the U.S.  FORMTEXT        FORMTEXT       Telephone  FORMTEXT       Fax  FORMTEXT       Email  FORMTEXT        Current Employment Information Present Employer (Company Name)  FORMTEXT       Street  FORMTEXT       City  FORMTEXT       State  FORMTEXT       Zip  FORMTEXT       Telephone  FORMTEXT       Fax  FORMTEXT       Email  FORMTEXT       Address of your current work location (if different from above)  FORMTEXT        FORMTEXT       Job Title  FORMTEXT       Current Salary $  FORMTEXT       per  FORMTEXT       Your Appointment at Norfolk State University Name of NSU department sponsor corresponding with you  FORMTEXT       Telephone/email of department representative  FORMTEXT       NSU department  FORMTEXT       Date(s) of previous affiliation with NSU, if any  FORMTEXT       Means of Support while in U.S. (attach proof of financial support if not paid by NSU)  FORMCHECKBOX  Norfolk State University Amount in U.S. Dollars $  FORMTEXT        FORMCHECKBOX  Personal Funds Amount in U.S. Dollars $  FORMTEXT        FORMCHECKBOX  U.S. Government Agency Name of Organization/Gov t Agency  FORMTEXT       Amount in U.S. Dollars $  FORMTEXT        FORMCHECKBOX  Your Government Amount in U.S. Dollars $  FORMTEXT        FORMCHECKBOX  Other (specify)  FORMTEXT       Amount in U.S. Dollars $  FORMTEXT        U.S. Visa History Are you currently in the U.S.?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, indicate date of last arrival  FORMTEXT       City  FORMTEXT       State  FORMTEXT       If yes, please indicate current non-immigrant (visa) status  FORMTEXT       Date status expires  FORMTEXT       and check one:  FORMCHECKBOX  I will be leaving the U.S. and returning before I begin my appointment at NSU Give destination and travel dates:  FORMTEXT        FORMCHECKBOX  I am requesting a transfer or extension of my current visa status  FORMCHECKBOX  I am requesting a change in visa status to:  FORMTEXT       If you are not currently in the U.S: At which consulate/embassy will you apply for your visa?  FORMTEXT        FORMTEXT       City Country Proposed U.S. arrival city/state  FORMTEXT       If you are not currently in the U.S. OR a requested extension of stay or change of status cannot be granted, give the U.S. consulate or inspection facility you want notified if the petition is approved: Type of Office  FORMCHECKBOX  Consulate  FORMCHECKBOX  Pre-flight inspection  FORMCHECKBOX  Port of Entry Office Address (City)  FORMTEXT       U.S. State or Foreign Country  FORMTEXT       Alien Registration Number A-  FORMTEXT       I-94 Number  FORMTEXT       I-94 Expiration Date  FORMTEXT       Non-immigrant Visa Number  FORMTEXT       Visa Expiration Date  FORMTEXT       I-797 Number  FORMTEXT       I-797 Expiration Date  FORMTEXT       EAD Number  FORMTEXT       EAD Expiration Date  FORMTEXT       *Attach a photocopy of all previous visa documents including Form I-94, DS-2019, I-20 Forms, H-1B approval notices, EAD cards, etc. All Applicants Must Complete: Have you ever been in the U.S. in any visa class other than tourist?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, please complete this section. Begin with your most recent visa class and work backwards chronologically. Visa classification Begin and end dates of status Purpose of stay and location (school or institution)  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       If you have previously held H-1B status, please give the dates of your periods of stay in H-1B classification in the U.S. Please write dates as month/day/year. Entered U.S. (mm/dd/yyyy) Left U.S. (mm/dd/yyyy) Entered U.S. (mm/dd/yyyy) Left U.S. (mm/dd/yyyy) 1.  FORMTEXT        FORMTEXT       5.  FORMTEXT        FORMTEXT       2.  FORMTEXT        FORMTEXT       6.  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hhCJOJQJ^JaJh!CJOJQJ^JaJh!CJOJQJ^J.jTh6h6>*CJOJQJU^Jh6>*CJOJQJ^JhW`CJOJQJ^JhW`>*CJOJQJ^J-jh6>*CJOJQJU^JmHnHu"jh6>*CJOJQJU^J.j?Th6h6>*CJOJQJU^J!j8~8888888888888888888888888889ȱȤȱȤhȱȤVIhl>*CJOJQJ^J"jhl>*CJOJQJU^J.jVh6h6>*CJOJQJU^J.jUh6h6>*CJOJQJU^JhW`CJOJQJ^JhW`>*CJOJQJ^J-jh6>*CJOJQJU^JmHnHu"jh6>*CJOJQJU^J.j+Uh6h6>*CJOJQJU^Jh6>*CJOJQJ^J9999 9&9(9092949H9J9L9V9X9\9^9`9b9v9ֲֿu]Fu-jh6>*CJOJQJU^JmHnHu.jWh6h6>*CJOJQJU^Jh6>*CJOJQJ^J"jh6>*CJOJQJU^JhW`CJOJQJ^J#hh>*CJOJQJ^JaJhW`>*CJOJQJ^J-jhl>*CJOJQJU^JmHnHu"jhl>*CJOJQJU^J.jVhlhE>*CJOJQJU^Jv9x9z9999999999999999999ֲֲֿֿ֙obJo.jeXhlhE>*CJOJQJU^Jhl>*CJOJQJ^J"jhl>*CJOJQJU^J.jWh6h6>*CJOJQJU^Jh6>*CJOJQJ^JhW`CJOJQJ^JhW`>*CJOJQJ^J-jh6>*CJOJQJU^JmHnHu"jh6>*CJOJQJU^J.jyWh6h6>*CJOJQJU^J99999999: "&(*,@BDNPT^`ɸɚs\ɬɚD\ɬ.jSYh6h6>*CJOJQJU^J-jh6>*CJOJQJU^JmHnHu.jXh6h6>*CJOJQJU^JUh6>*CJOJQJ^J"jh6>*CJOJQJU^JhW`CJOJQJ^J hhCJOJQJ^JaJhW`>*CJOJQJ^J"jhl>*CJOJQJU^J-jhl>*CJOJQJU^JmHnHuFORMTEXT        FORMTEXT       7.  FORMTEXT        FORMTEXT       4.  FORMTEXT        FORMTEXT       8.  FORMTEXT        FORMTEXT       Where have you lived for the past five years? Do not include places you have visited for periods of six months or less. Countries City From (mm/dd/yy) To (mm/dd/yy)  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       Have you ever been denied H-1B status?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Have you ever filed, or has anyone ever filed for you, an application for permanent resident (green card) status?  FORMCHECKBOX  yes  FORMCHECKBOX  no If you answered yes, please attach a separate sheet and explain (give dates and places of filing, name of person who filed, relationship of that person to you, final decision on application, and current status of application.) Are you a J-1 Exchange Visitor?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, are you subject to the 2-year foreign residency requirement?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Are you currently in removal proceedings?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Family Information Please complete this section for any family members who will travel with you to the U.S. or who will arrive later to join you. If your family will travel to the U.S. separately, a visa document will be prepared to allow them to enter the U.S. Only your spouse and minor children (under age 21) may be included as family members. 1. Name of Family Member Date of Birth Alien Registration Number  FORMTEXT        FORMTEXT       A-  FORMTEXT       City & Country of Birth Citizenship Relationship  FORMTEXT        FORMTEXT        FORMTEXT       2. Name of Family Member Date of Birth Alien Registration Number  FORMTEXT        FORMTEXT       A-  FORMTEXT       City & Country of Birth Citizenship Relationship  FORMTEXT        FORMTEXT        FORMTEXT       3. Name of Family Member Date of Birth Alien Registration Number  FORMTEXT        FORMTEXT       A-  FORMTEXT       City & Country of Birth Citizenship Relationship  FORMTEXT        FORMTEXT        FORMTEXT        FORMCHECKBOX  Family with travel to U.S. with me  FORMCHECKBOX  Family will remain in home country  FORMCHECKBOX  Family will arrive later Expected arrival date  FORMTEXT        FORMCHECKBOX  Family is in U.S. and needs to apply for a change of status Current non-immigrant (visa) status  FORMTEXT        FORMCHECKBOX  Family is in U.S. and does not need to apply for a change of status Current visa status  FORMTEXT       **If your family is already in the U.S. with you, please attach copies of passport data and expiration pages, I-94 cards, and Social Security cards, if applicable. If applying for change of status, please complete Form I-539 and attach check for $195, copies of passport, I-94, marriage certificate, birth certificates, and/or all prior INS filings and INS notices as applicable.  Documents to be Provided: Document Name Status  FORMCHECKBOX  Copy of Job Offer  FORMCHECKBOX  Attached  FORMCHECKBOX  To be provided  FORMCHECKBOX  N/A  FORMCHECKBOX  Copy of Job Description or Job Announcement  FORMCHECKBOX  Attached  FORMCHECKBOX  To be provided  FORMCHECKBOX  N/A  FORMCHECKBOX  Passport/Visa for each beneficiary/applicant  FORMCHECKBOX  Attached  FORMCHECKBOX  To be provided  FORMCHECKBOX  N/A  FORMCHECKBOX  Current I-94 Cards (If in U.S.)  FORMCHECKBOX  Attached  FORMCHECKBOX  To be provided  FORMCHECKBOX  N/A  FORMCHECKBOX  Current Resume  FORMCHECKBOX  Attached  FORMCHECKBOX  To be provided  FORMCHECKBOX  N/A  FORMCHECKBOX  Diplomas  FORMCHECKBOX  Attached  FORMCHECKBOX  To be provided  FORMCHECKBOX  N/A  FORMCHECKBOX  College/Graduate Transcripts  FORMCHECKBOX  Attached  FORMCHECKBOX  To be provided  FORMCHECKBOX  N/A  FORMCHECKBOX  Most Recent Pay Stub  FORMCHECKBOX  Attached  FORMCHECKBOX  To be provided  FORMCHECKBOX  N/A  FORMCHECKBOX  All prior INS Filings and INS Notices  FORMCHECKBOX  Attached  FORMCHECKBOX  To be provided  FORMCHECKBOX  N/A I, the undersigned, (i) hereby certify that the information provided herein and the documents provided pursuant to this request are true, correct, and complete, (ii) understand that I have been advised to provide all information regarding my current and past immigration history, (iii) understand that I may be restricted from traveling during the processing of my visa and that I should provide to the Office of International Student Services all future travel information, (iv) understand that all processing times provided by the Office of International Student Services are estimates, that United States Citizenship and Immigration Services (USCIS) processing times cannot be predicted with certainty and that Norfolk State University nor any immigration representative can guarantee a favorable result from the USCIS, and (v) acknowledge that the Office of International Student and Scholar Services represents Norfolk State University in this petition. Your signature Date  FORMTEXT       Please return this completed form to: The Office of International Student Services James A. 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