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IR-US Innovation Summit Intake Form.

Personal Information

Required Field:*
Additional Information May Be Needed+
- Full Name*
  
  Please enter your full name.
- Other Names Used
- Gender*
  
  Please enter your gender.
- Marital Status*
  
  Please enter your marital status.
- Date of Birth*
  
  Please enter your date of birth.
- Birth Place*
  
  Please enter your birth place.
- Nationality*
  
  Please enter your nationality.
- Do you hold or have you held any nationality other than the one indicated above (Please specify)?*
  
  Please confirm if you have held any additional nationality.
- Are you a permanent resident of a country other than your country of origin (Please specify)?*
  
  Please confirm your permanent residence.
- Address*
  
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- City*
  
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- State/Province*
  
  Please enter your state or province.
- Zip/Postal Code*
  
  Please enter your zip or postal code.
- Country*
  
  Please enter your country.
- Mailing Address (If different)
- Primary Phone*
  
  Please enter your phone number.
- Secondary Phone
- Work Phone
- Email*
  
  This isn't a valid email address.
  
  Please enter your email address.
- Have you ever lost a passport or had one stolen?*
  - Yes
  - No
  Please confirm if your passport has ever been lost or stolen.
Travel Information

Required Field:*
Additional Information May Be Needed+
- Person/Entity Paying for Your Trip*
  
  Please specify the person or entity that is paying for your trip.
- Are there other persons traveling with you (Please specify)?*
  
  Please specify the person or entity that is paying for your trip.
- Have you ever been in the U.S.?*
  - Yes
  - No
  Please specify if you have been to the US.
- Have you ever been issued a U.S. visa?*
  - Yes
  - No
  Please specify if you have been issued a US visa.
- Have you ever been refused a U.S. visa, or been reused admission to the U.S., or withdrawn your application for admission at the port of entry?*
  - Yes
  - No
  Please specify if you have been refused a US visa, admission or withdrawn your application.
- Has anyone ever filed an immigrant petition on your behalf with the U.S. Citizenship and Immigration Services?*
  - Yes
  - No
  Please specify if anyone ever filed an immigrant petition on your behalf.
- Have you traveled to any countries within the last five years?*
  - Yes
  - No
  Please specify if you have traveled to any countries within the last five.
- Have you resided in any country for six months or longer since you attained 16 years of age?*
  - Yes
  - No
  Please specify if you have resided in any country for six months or longer since you attained 16 years of age.
Family Information

Required Field:*
Additional Information May Be Needed+
- Father's Name*
  
  Please enter your father's name.
- Father's Date of Birth*
  
  Please enter your father's date of birth.
- Is your Father still living* +
  - Yes
  - No
  Please select an option.
- Mother's Name*
  
  Please enter your mother's name.
- Mother's Date of Birth*
  
  Please enter your mother's date of birth.
- Is your Mother still living* +
  - Yes
  - No
  Please select an option.
- Father's Address*
  
  Please enter your father's address.
- Mother's Address (If different)
- Is your father in the U.S?*
  - Yes
  - No
  Please specify if your father is in the US.
- Is your Mother in the U.S?*
  - Yes
  - No
  Please specify if your mother is in the US.
- Do you have other relatives in the U.S?*
  - Yes
  - No
  Please specify if you have other relatives in the US.
Work / Education Training Information

Required Field:*
Additional Information May Be Needed+
Are you currently employed?* +
- Yes
- No
Please specify if you were previously employed.
- Current Employment Information
- Primary Occupation*
  
  Please enter your primary occupation.
- Employee Address*
  
  Please enter your employee address.
- Supervisor's Name*
  
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- Employee Phone*
  
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- Job Title*
  
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- Employment Start Date*
  
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- Employment End Date
- Briefly describe your duties*
  
  Please describe your duties.
Were you previously employed?* +
- Yes
- No
Please specify if you were previously employed.
- Most Previous Employment Information
- Previous Occupation*
  
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- Previous Employment Address*
  
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- Previous Supervisor's Name*
  
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- Previous Employee Phone*
  
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- Previous Job Title*
  
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- Employment Start Date*
  
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- Employment End Date*
  
  Please enter your employment end date.
- Briefly describe your duties*
  
  Please describe your duties.
Have you ever attended any educational institutions at a secondary level or above?* +
- Yes
- No
Please specify if you attended any educational institutions.
- Recent Education Information
- Insitution Name*
  
  Please enter the institution name.
- Insitution Address*
  
  Please enter the institution address.
- Course of Study*
  
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- Date of Attendance From*
  
  Please enter your date of attendance.
- Date of Attendance To*
  
  Please enter your date of attendance.
- Languages You Speak*
  
  Please enter at lease one language.
Have you you belonged to, contributed to, or worked for any professional, social, or charitable organization?*
- Yes
- No
Please specify if you belonged to, contributed to, or worked for any professional, social, or charitable organization.
Do you have any specialized skills or training, such as firearms, explosives, nuclear, biological or chemical experience?*
- Yes
- No
Please specify if you have any specialized skills or training, such as firearms, explosives, nuclear, biological or chemical experience.
Have you ever served in the military?*
- Yes
- No
Please specify if you have ever served in the military.
Have you ever served in, been a member of, or been involved with a paramilitary unit, vigilante unit, rebel group, guerrilla group, or insurgent organization?*
- Yes
- No
Please specify if you have ever served in, been a member of, or been involved with a paramilitary unit, vigilante unit, rebel group, guerrilla group, or insurgent organization.

Takhsh Law, P.C.
Chicago Immigration Lawyer
701 Main Street, Suite 204, Evanston, IL 60202 View Map
Call Today (312) 561-3735 | Local (844) 344-2628
Website: http://www.takhshlaw.com/
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