INFORMATION ABOUT YOU

1. Name - (exactly as it appears on your Alien Registration Card):

2. Alien Registration Number (A#): 3. Social Security #:

4. Your name (Full true and correct name, if different from above):

5. Other Names you have used: Including maiden name: 

6. You may, by law, change your name at the time you are naturalized. If you wish to do so,
please print the name:

7. Date Of Birth: Day: Month: Year:

8. Sex: Female Male

9. Place of Birth: City State Country
10. Was your father or mother ever a U.S. Citizen? Yes No (if yes explain):

11. Can you read and write English? Yes No

12. Can you speak English? Yes No

13. Can you sign your name in English Yes No

14. Date you were admitted for permanent residency:

15. Place you were admitted for permanent residency:

16. Date your continuous residency began in the U.S.:

17. How long have you continuously resided in the State where you now live? (months):

18. Do you intend to reside permanently in the United States? Yes No if no explain fully:

19. Have you served in the U.S. Armed forces? Yes No (if yes, complete the following): Branch of Service (indicate if Reserve or National Guard): Inducted Enlisted
Location where you entered: Service began date: Service ended Date: Service number: Rank at discharge: Type of discharge:
Reason for discharge (alienage, conscientious objector, other):

20. Address in U.S. during last 5 years (present address first): Street and Number: City/State/Country: From: To: Street and Number:

City/State/Country:

From: To:
Street and Number:

City/State/Country:

From: To:
21. What employment have you held during the last 5 years (list present employment first):

Name of Employer: Occupation: City/State/Country: From: To:

Name of Employer: Occupation: City/State/Country: From: To:
Name of Employer: Occupation: City/State/Country: From: To:
22. Married Single Widowed Divorced. INFORMATION ABOUT YOUR SPOUSE:

Date of birth: Country of birth:

Place he or she entered the U.S.
Date of entry into U.S.

Alien Registration number:
Present Immigration status:

Date Naturalized: ___________ Place Naturalized

Present Address: 24. Names of Prior Husbands/Wives:

Date of marriage: Date Marriages Ended:

How marriage ended:
Alien Citizen Names of Prior Husbands/Wives:

Date of marriage: Date Marriages Ended:

How marriage ended:
Alien Citizen

25. Complete if your present husband/wife was previously married - total number of times: _______

Names of Prior Husbands/Wives:

Date of marriage: Date Marriages Ended:

Names of Prior Husbands/Wives:

Date of marriage: Date Marriages Ended:

Names of Prior Husbands/Wives:

Date of marriage: Date Marriages Ended:

How marriage ended:
Alien Citizen

Name: Date of Birth:

Country of Birth:

Date of entry: Port of entry:
Location of child now:

Alien Reg. Number Male Female

Country of Birth

Date of entry: Port of entry: Location of child now:
Alien Reg. Number

Name: Date of Birth:

Date of entry: Port of entry: Location of child now:

Returned at (place/port) Date departed

Date returned:

Ship/airline/railroad/or bus company - or other means used to return to the U.S.:

Returned at (place/port) Date departed

Ship/airline/railroad/or bus company - or other means used to return to the U.S.:

Returned at (place/port) Date departed

28. Complete the following with regard to each absence you have had from the U.S. for a period of six months or more since you entered for permanent residence.

Ship/airline/railroad/or bus company - or other means used to return to the U.S.:

Returned at (place/port) Date departed

Ship/airline/railroad/or bus company - or other means used to return to the U.S.:

Returned at (place/port) Date departed

Ship/airline/railroad/or bus company - or other means used to return to the U.S.:

Returned at (place/port) Date departed

Ship/airline/railroad/or bus company - or other means used to return to the U.S.:

29. The law provides that you may not be regarded as qualified for citizenship if you committed certain offenses or crimes, even if you were not arrested. Have you ever in or outside the U.S.:
a) Knowingly committed any crime for which you have not been arrested?Yes No
b) Been arrested, cited, charged, indicted, convicted, fined or imprisoned for breaking the law,
including traffic regulations? Yes No
If yes to (a) or (b): Where was the violation? Date of Offense: Nature of Offense:

Outcome of case, if any: Where was the violation?

Date of Offense: Nature of Offense:

Outcome of case, if any:

Where was the violation?

Date of Offense: Nature of Offense:

Outcome of case, if any:

30. List your present and past membership in or affiliation with every association/fund/foundation/
party club/society or similar group in the U.S. or in any other place and foreign military services. Name of organization: Location of organization: Membership from: Membership to:
Name of organization:

Location of organization:

Membership from: Membership to:
Name of organization:

Location of organization:

31. Are you now, or have you ever, in the U.S. or in any other place, been a member of, or
in any way connected or associated with the Communist Party? Yes No

32. Have you ever knowingly aided or supported the Communist Party directly, or indirectly through
another organization, group or person? Yes No

33. Do you now or have you ever advocated, taught, believed in or knowingly supported or furthered the interests of Communism? Yes No

34. During the period March 23, 1933 to May 8, 1945, did you serve in, or were you in any way
affiliated with, either directly or indirectly, any military unit, paramilatary unit, police unit, self
defense unity, vigilante unit, citizen unit, unit of the Nazi Party or SS. government agency or office,
extermination camp, concentration camp, prisoner of war camp, prison labor camp, detention camp
or transit camp, under the control or affiliated with;
a) Nazi Government of Germany? Yes No
b) any government in any area occupied by, allied with, or established with the assistance or
cooperation of, the nazi Government of Germany? Yes No

35. During the period of March 23, 1933 to May 8, 1945, did you ever order, incite, assist, or otherwise
participate in the persecution of any person because of race, religion, national origin, or political
opinion? Yes No

36. Were you born with, or have you acquired in some way, any title or order of nobility in any foreign state?
Yes No

37. Have you ever been declared legally incompetent or have you ever been confined as a patient in a mental institution? Yes No

38. Are deportation proceeding pending against you, or have you ever been deported or ordered
deported, or have you ever applied for suspension of deportation?
Yes No

39. When was you last federal income tax return filed? Year:

40. Since becoming a permanent resident of the United States, have you filed an income tax return as a nonresident? Yes No

41. Since becoming a permanent resident of the U.S. have you failed to file an income tax return because you regarded yourself as a nonresident?
Yes No

42. Have you ever claimed in writing, or in any other way, to be a U.S. Citizen?
Yes No

43. Have you ever deserted from the military, air or naval forces of the U.S.?
Yes No

44. Have you ever left the U.S. to avoid being drafted into the Armed Forces of the U.S.?
Yes No

45. Do you believe in the Constitution and form of government of the United States?
Yes No

46. Are you willing to take the full oath of allegiance to the U.S.?
Yes No

47. If the law requires it, are you willing to bear arms on behalf of the U.S.?
Yes No

48. If the law requires if, are you willing to perform noncombatant services in the Armed Services of the U.S.?
Yes No

49. If the law requires it, are you willing to perform work of national importance under civilian direction?
Yes No

50. Did you ever apply for exemption from military service because of alienage, conscientious objections, or other reasons? Yes No

51. Did you ever register under U.S. Selective Service laws or draft laws?
Yes No

52. The law provides that you may not be regarded as qualified for naturalization , if, at any time
during the period for which you are required to prove good moral character, you have been a
habitual drunkard; advocated or practiced polygamy; have been a prostitute or procured anyone
for prostitution; have knowingly and for gain helped any alien to enter the U.S. illegally; have been
an illicit trafficker in narcotic drugs or marijuana; have received your income mostly from illegal
gambling, or have given false testimony for the purpose of obtaining any benefits under the Act.

Have you ever, anywhere, been such a person or committed any of these acts? Yes No

Name:
Signature: ____________________________ Date: Phone number:

Email id:

Two Step process, This is STEP 1.