APPLICATION

of citizen of UKRAINE who is a permanent resident of the USA

1.

Name: First, patronymic and last names

 

2.

Date of birth: DD/MM/YY

 

3.

Place of birth

 

4.

Nationality (Ethnic origin)

 

5.

Passport number

 

6.

Education and profession (Name of School & completion date)

 

7.

When and reason for leaving Ukraine

8.

Identify last Country prior to entering the USA

 

9.

Address and ph. number in the USA

 

10.

Place and address of work in the USA

 

11.

Names of relatives and their addresses in Ukraine

 

12.

Names of relatives and their addresses outside Ukraine, including those who came with you

 

13.

Names of children entered into your passport

 

 

                     Date: _______________________		Signature:    ______________________