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A Tradition of Fine Lawyering IMMIGRATION, CRIMINAL DEFENSE, FAMILY LAW & DIVORCE, ESTATE PLANNING VINCENT P. MARTIN ZACHARY AAKER MARIA TRAFTON ROBERT A. YARD* MAURY D. BEAULIER* AYAN AHMED: LEGAL ASSISTANT SARA KETTERING: PARALEGAL CYNTHIA HERMES: OFFICE ASSISTANT *OF COUNSEL GENERAL IMMIGRATION QUESTIONNARE Date: _________________________________ Conflicts:______Initials:_________ Name: _______________________________________________________________________________________________________ Address (complete – street address, apartment number, city, state and zip code): _____________________________________________________________________________________________________________ Contact Number: _______________________________________________________________________________________________ E-Mail: _______________________________________________________________________________________________________ Would you like to receive our Immigration Newsletter regarding the latest immigration news? YES NO Date of Birth: ______________________________________ Place of Birth: _______________________________________________ Occupation: ____________________________________ Employer Name: _______________________________________________ Employer Address: _____________________________________________________________________________________________ Spouse/Fiancé(e) Name (if applicable): _____________________________ Spouse’s/Fiance(e)’s date of birth:____________________ Spouse’s/Fiancé(e)’s country of residence/citizenship (if applicable):______________________________________________________ When did you arrive in the United States? ___________________________________________________________________________ Do you have legal immigration status in the United States?.......................................................................................... If yes, what status? ________________________________ Did you enter the U.S. legally?................................................................................................................................. Have you ever been sent back to your home country or ordered to leave the United States by any U.S. government official?.......................................................................................... Do you have a parent or grandparent who is/was a United States Citizen or Legal Permanent Resident?...................................................................................................................................... Since your arrival in the United States, have you worked?...................................................................................... Have you (or has anyone else) ever submitted an application or petition of any kind to U.S. Immigration to help you, your spouse, an ex-spouse, or any of your children to get legal immigration status in this country?................................................................................................. Have you ever been married?................................................................................................................................... If yes, what is his/her immigration status? ________________ Have you ever been accused of a crime or offense and/or arrested anywhere in the world?.................................... If this is a marriage based case, do you have questions about a Prenuptial Agreement?.......................................... Do you have any questions about divorce or criminal defense?............................................................................. Have you spoken with another attorney regarding your case?.................................................................................. Have you hired another attorney?.............................................................................................................................. U-Visa eligibility - have you been the victim of a crime?.................................................................................................... YES NO YES NO YES NO YES YES NO NO YES YES NO NO YES NO YES NO YES NO YES NO YES NO YES NO Briefly explain the reason you are here today: ________________________________________________________________________ _____________________________________________________________________________________________________________ How were you referred to our office? _____________________ Provide website if found online:_______________ ________________ _____ Initial Here – The consultation fee is $60.00. I understand that this initial consultation does not create an attorney/client relationship. I understand that Cundy and Martin, LLC is not my attorney and that I should not rely on any information from this initial consultation as legal advice. All information provided is confidential. DEFERRED ACTION FOR CHILDHOOD ARRIVALS (DACA) Did you enter the U.S. before your 16th birthday?..................................................YES/NO Were you under the age of 31 as of June 15, 2012…………………………….…YES/NO Have you continuously resided in the U.S. since June 15, 2007 up to the present time? ………………………………………………………………… YES/NO Had no lawful status on June 15, 2012?.................................................................YES/NO Are you currently in school, have you graduated or obtained a certificate of completion from high school, have you obtained a general education development (GED) certificate, or are you an honorably discharged veteran of the Coast Guard or Armed Forces of the United States?.......................................................……………………………….. YES/NO Have you been convicted of a felony, significant misdemeanor, or three or more other misdemeanors, and do not otherwise pose a threat to national security or public safety?........................................................ YES/NO _________________________________________________________________________