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Beneficiary Information CƻNJƳ

*PLEASE SUBMIT THIS FORM TO YOUR SPONSORING DEPARTMENTϝ

The following information is required for the preparation of the H-1B, O-1, TN, E-3 or PR petition on yourbehalf. Answer all relevant questions. Failure to complete all relevant questions or writing unclearly may delay the filing of your application.

Personal Information

Must be filled out completely. If it does not apply to you, please write “N/A.” Do not leave any spaces blank.

1. Legal name (as it appears on your passport)

Surname (Last Name): _________________________________________________________

Given Name (First/Middle Name): ________________________________________________

2. Other names used, including maiden names, shortened names, secondary last names, previous names fromother marriages, alternative published names, or any Anglicized names.________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

3. Date of birth: __________________ ______ ________

4. Gender: Male Female

5. Marital Status: Single Married (fill out spouse's information on page 3)

6. City/Town/Village of birth: _______________________________________________

7. State/Province of birth: ______________________________________________ N/A

8. Country of citizenship: __________________________________

9. Country of nationality: ___________________________________________

10. Do you currently live in the U.S.? Yes No

If yes, please provide your current address:Street number and name: _________________________________________________________________

Apartment #____ Suite #____ Floor #____

City or Town: ________________________________ State: _______________________ ZIP: ___________

11. E-mail address: _____________________________________________________

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Passport Information

Do you have a valid passport*? Yes No *Passports must be valid for at least 6 months past the start date of this petition. If it is not, we recommend renewing your passport before we will submit the petition.

Do you have a valid passport from more than one country? Yes No If yes, which passport are you going to use for this petition? ______________________________ Please list all current valid passports below: Passport 1 Passport number: _________________________________

Country that issued your passport: ________________________________ Passport issue date (mm/dd/yyyy): ________________________________ Passport expiration date (mm/dd/yyyy): ____________________________

Passport 2 Passport number: _________________________________

Country that issued your passport: ________________________________ Passport issue date (mm/dd/yyyy): ________________________________ Passport expiration date (mm/dd/yyyy): ____________________________

Future Travel Plans

LŦ ȅƻdz ŀNJŜ ƴƻǘ ŎdzNJNJŜƴǘƭȅ ƛƴǎƛŘŜ ǘƘŜ ¦{Σ LJƭŜŀǎŜ ǎƪƛLJ ǘƻ CƛƭƛƴƎ LƴŦƻNJƳŀǘƛƻƴ ōŜƭƻǿΦ Do you or your dependents have plans to travel to/from the U.S. in the next 6 months? Yes No If yes, dates of travel: ________________________ where? ___________________________

²Ƙƻ ƛǎ ǘNJŀǾŜƭƛƴƎΚ*Traveling ǿƘile certain petitions are pending with U.S. Citizenship and Immigration Services (USCIS) may be an issue. Please speak to IFSS about your pending travel plans as soon as possible.

Filing Information

Are you currently or will you be inside the U.S. when this petition is filed? Yes (skip to next section) No

No

If you will apply for your visa stamp abroad, please list the city and country of the U.S. consulate/embassy (http://www.usembassy.gov/) where you will/would apply for the visa:

City: ______________________________ Country: ______________________________

Please provide a foreign residential/home address (can be a parent, relative, friend, etc. if you do not have one) Street number and name: _________________________________________________________________

Apartment #____ Suite #____ Floor #____ City or Town: _______________________________________ State: _______________________________ Province: ___________________________________ N/A Postal code: ___________________ N/A Country: _____________________________________

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Family Information

Do you have a spouse and/or children? Number of Spouse and Children: _____ To be eligible for H-4 status, one must be a legally married spouse or child under the age of 21 and born outside the U.S.

Check all that apply: My family members are inside the U.S. and will need to file the form I-539 to petition for their H-4 status. My family members are outside the U.S. and do not need to file the I-539. They will use my I-797 approval

notice to get their H-4 status when entering the U.S. My family members do not require H-4 status. Please explain:

Please list the names of ȅƻdzNJ spouse andκƻNJ children: Dependent 1 Relationship: Spouse Child Country of birth: _____________________________

Legal name (as it appears on your passport) Country of citizenship: ________________________

Surname (Last Name): _________________________________________________________

Given Name (First/Middle Name): ________________________________________________

Date of birth: __________________ ______ ________

Gender: Male Female

Dependent 2

Relationship: Spouse Child Country of birth: _____________________________

Legal name (as it appears on your passport) Country of citizenship: ________________________

Surname (Last Name): _________________________________________________________

Given Name (First/Middle Name): ________________________________________________

Date of birth: __________________ ______ ________

Gender: Male Female

Dependent 3

Relationship: Spouse Child Country of birth: _____________________________

Legal name (as it appears on your passport) Country of citizenship: ________________________

Surname (Last Name): _________________________________________________________

Given Name (First/Middle Name): ________________________________________________

Date of birth: __________________ ______ ________

Gender: Male Female

If you ƴŜŜŘ ƳƻNJŜ ǎLJŀŎŜ, please print and complete another page

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Did you obtain your highest degree from a U.S. Institution? Yes No Please list your highest degree only below:

Type of Degree: ___________________________ Have you graduated? No Yes, list year: ____________

Name of university: ______________________________________________________________________

Major/ Primary Field of study: ______________________________________________________________

Address of university:

City or Town: _______________________________________ State: _______________________________ Province (if not in the US): ___________________________ N/A Postal code: ____________ N/A Country (if not in the US): _____________________________________

Does your position require you to obtain licensure in the State of Wisconsin? Yes No

If yes, have you obtained Wisconsin licensure? Yes No In process

For employees who will have direct human patient contact (if not, skip to next section):

Are you a graduate of a foreign medical school? Yes No

Have you passed all three steps of the U.S. Medical Licensing Exam (for MDs) or the NBOME COMLEX-USA (for

DOs)? Yes No In process

If no, please explain: _______________________________________________________________

________________________________________________________________________________

Have you obtained certification from the Educational Commission for Foreign Medical Graduates (ECFMG)?

Yes

No

No, I am a graduate from a U.S. or Canadian medical school and do not require ECFMG certification

In process

Please note that a credential evaluation is now required for all diplomas granted from colleges, universities and institutions outside the U.S. and Canada. It will be the responsibility of either the beneficiary or the department to obtain the credential evaluation. NACES (National Association of Credential Evaluation Services) can provide you with a list of accredited services to get your foreign studies evaluated: http://naces.org/members.html. You can also find other services that are not accredited by doing an online search. IFSS cannot recommend one company over another.

NOTE: Foreign medical graduates who have ECFMG certification do not need an additional credential evaluation.

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Current Immigration Status NOTE: I-94’s are now found online at www.cbp.gov/i94

If you are not currently inside the US, leave this section blank and please skip to Immigration Status HistoryCurrent Immigration Status: _______________ Date of last arrival in the U.S. (mm/dd/yyyy): _____________ Date status expires (mm/dd/yyyy) - look on your DS-2019, I-20 or I-797: ________________ I-94 Number: ______________________________ I-94 Expiration Date (mm/dd/yyyy or D/S): ________________ Immigration status on I-94 card (may be different than current status): ________________________ Are you currently in removal proceedings? Yes No

Immigration Status History

1. Have you EVER been in H-1B or O-1 status in the past? Yes No (if no, skip to question 2)

Which status? H-1B O-1 Have you ever been denied? Yes No

If yes, please explain: _____________________________________________________________ _______________________________________________________________________________

Provide all receipt numbers & expiration dates (see sample on first line below). Receipt number: WAC-12-123-12345_ Validity dates (mm/dd/yyyy): 01/01/2015 – 12/31/2018_________ Receipt number: __________________ Validity dates: _______________________________ Receipt number: __________________ Validity dates: _______________________________ Receipt number: __________________ Validity dates: _______________________________ Receipt number: __________________ Validity dates: _______________________________ Receipt number: __________________ Validity dates: _______________________________ Dates when you have been physically present inside the U.S. in H-1B or O-1 Status. DO NOT list the validity

dates of your H-1B statuses (as you did above). Attach a separate sheet if needed. From (mm/dd/yyyy): _3/15/2015 (date you entered the U.S.) To (mm/dd/yyyy): _4/6/2015 (date you left the U.S.)

From: _______________ To: ________________ From: _______________ To: ________________ From: _______________ To: ________________ From: _______________ To: ________________ From: _______________ To: ________________ From: _______________ To: ________________

2. Have you EVER been in F-1 status in the past? Yes No (if no, skip to question 3) Expiration date or end date of I-20 (mm/dd/yyyy): _____________________ Are you currently on OPT (Optional Practical Training)? Yes No

If yes, what is end date listed on your Employment Authorization Document (EAD) card (mm/dd/yyyy): _________________ EAD card number (starts with LIN, WAC, EAC, SRC, MSC): ________________________

Student & Exchange Visitor Information System (SEVIS) #: N______________________________

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3. Have you EVER been in J-1 or J-2 status in the past? Yes No (if no, skip to question 4)

Student & Exchange Visitor Information System (SEVIS) #: N_________________________________ Start and end date of program (mm/dd/yyyy-mm/dd/yyyy): _____________________ J-1 Category (student, professor, research scholar, etc.): ________________________ Are you subject to the two-year home residence requirement? Yes No (skip to next section)

If no, have you applied for a waiver? Yes No* If yes, have you received the Department of State recommendation? Yes No* If yes, have you received your I-612 approval notice? Yes No*

*If no, we will not be able to process your H-1B application until such time as you receive the I-612 approval notice from U.S. Citizenship and Immigration Services.

4. Are you CURRENTLY inside the U.S. in B-1/B-2 status? Yes No (if no, skip to question 5)

Which status: B-1/B-2 WB/WT (this indicates you were admitted on the Visa Waiver Program) Expiration date or end date (on I-94 card; mm/dd/yyyy): _____________________

5. Are you currently in the process of applying for Permanent Residency? Yes No (if no, skip to

signature space) Has a labor certification been filed on your behalf by a U.S. employer? Yes No If yes, please provide the following: Date of filing (mm/dd/yyyy): _________________________ Name of employer: _______________________________________________________

The labor certification is/has been: Certified In Process Denied Has an immigrant petition (I-140 or I-130) been filed? Yes No If yes, name of petitioner: ______________________________________________________ Filed under what category? (Extraordinary Ability, National Interest Waiver, Marriage based, etc.) ____________________________________________________________________________ Has the immigrant petition been approved? Yes No If yes, please provide the following:

Date (mm/dd/yyyy): _______________ Case Number: ____________________________ Have you filed for adjustment of status to Permanent Residency (I-485)? Yes No If yes, what was the date of filing? (mm/dd/yyyy): ____________________________________ Has it been approved? Yes No If yes, please provide the date of approval (mm/dd/yyyy): _________________________

Have you applied for your Employment Authorization Document (EAD) (I-765)? Yes No If yes, expiration date (mm/dd/yyyy): ____________________ Have you applied for Advance Parole (AP) (I-131)? Yes No If yes, expiration date (mm/dd/yyyy): ____________________ If no, do you have a valid H-1B visa stamp in your passport? Yes No If yes, expiration date (mm/dd/yyyy): ____________________

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NOTE: H-1B employees whose labor certification and/or immigrant petition have been pending for more than 365 days and are nearing the six year limit on H-1B, may be eligible to file for an extension of their H-1B status. Extensions may be filed in one year increments until such time that the permanent residency has been approved. Extensions may be filed in three year increments if the applicant is unable to apply for adjustment of status because of the per country visa number retrogression but the I-140 has been approved. If this applies to you, please provide a copy of the following, as applicable: I-140 or I-130 receipt and/or approval notice I-485 receipt and/or approval notice EAD: I-765 receipt and/or approval notice Advance Parole: I-131 receipt and/or approval notice

Additional Information

If there is additional information you feel we should be made aware of, please let us know below. For example, do you have a change of status petition already pending with USCIS, are you anticipating an upcoming marriage or birth/adoption of a child, have you held any other immigration status that was not listed in this form already (TN, E-3, Asylee, etc.)?

Signature

You must sign or the application will be incomplete. To verify that all of the information above is accurate and complete, please sign below: Print name: _________________________________________________________________________________ Signature: __________________________________________________________________________________ Date: _______________

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Beneficiary Checklist

All applicants: (1 copy of each unless noted otherwise) Passport – biographical information page only (valid at least 6 months beyond start date of petition) Copy of diploma/certificate AND English translation* Copy of transcript (if your field of study is not indicated on diploma/certificate) AND English translation* Credential evaluation, if degree was earned abroad (except Canadians) – see note on page 4 regarding

ECFMG certification for clinical positions Current Curriculum Vitae or Resume

If currently in the U.S.: Copy of the I-94 (now obtained online at www.cbp.gov/i94) Copy of the visa page from your passport

If you are currently in F-1 or F-2 status, please also include:

Copies of all previous I-20(s) Copy of both sides of Employment Authorization Document (EAD), if on Optional Practical Training (OPT) If currently in F-2 status, submit copies of F-1’s I-94/visa/passport bio page

If you are currently or have ever been in J-1 or J-2 status, please also include:

Copies of all IAP-66(s) or DS-2019(s), front and back If currently in J-2 status, submit copies of J-1’s I-94/visa/passport bio page If subject to the 2 year home residence requirement (212e), provide the following:

o U.S. Department of State No Objection Letter AND I-612 USCIS Approval Noticeo OR, if you fulfilled the requirement, evidence you were in your home country for that time

If you have ever been in H-1B or H-4 status, please also include:

Copies of all previous I-797 Approval Notice(s) Copy of paystubs from the past 4 months If you currently hold H-4 status, copies of documents related to spouse’s H-1B including: employment letter, last

4 months pay stubs, H-1B Approval Notice(s), I-94, visa stamp, passport

If you have dependent(s) that are applying for H-4 status and are inside the U.S., please also include: Completed Form I-539 – must be signed in BLUE ink by dependent not the beneficiary Copies of all previous immigration documents (DS-2019, I-20 and/or I-797) Copies of the following for all dependent’s

o I-94o Visa page from passporto passport biographical page (valid at least 6 months beyond start date of petition)

Copies of the following for a dependent spouse:o Marriage certificate AND English translation*

Copies of the following for dependent children:o Birth certificate(s) AND English translation*

$370.00 filing fee for I-539 (Personal check or money order from a U.S. bank payable to the “U.S. Departmentof Homeland Security”). This cannot be paid by your department.

*TranslationsIf any documents are not in English, they must be translated. The beneficiary may not do the translating. The translationdoes NOT need to be done by a professional translator but it must contain the following statement. “I, (name), certifythat I am competent to translate from the (name of language) language into English and that the attached is theaccurate translation of the original documents.” The translation must also be signed and dated by the translator.