Section I: Visitor Information

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1 Office f Internatinal Affairs Bidata Infrmatin Frm Permanent Resident Sectin I: Visitr Infrmatin Date f Birth (MM/DD/YYYY) Address U.S. Residential Address: Street City State Zip Cde Telephne Number: Hme Cell Wrk Fax Gender: Male Marital Status: Single Married Female Other, please indicate: City f Birth Cuntry f Birth Cuntry f Citizenship Permanent Address in Hme Cuntry: Hme r Apartment # and Street City Cuntry State/Prvince Pstal Cde Sectin II: Immigratin Infrmatin U.S. Entry Infrmatin: Are yu currently in the U.S.? N If yes, please indicate yur current immigratin status: If yes, please prvide the 11-digit number n yur Frm I-94: Passprt Infrmatin: D yu have a passprt valid 6 mnths int the future? N If yes, please prvide the infrmatin belw: Name (as it appears n the passprt) Cuntry f Issuance Date f Expiratin Phne: Fax: utiahustn@uth.tmc.edu 7000 Fannin Street, Suite 130 Hustn, TX Web:

2 F Student Infrmatin: Have yu ever been in the U.S. n F-1 r F-2 visa status? N Did yu btain a degree frm a U.S. institutin? N If yes, what types f degree(s)? If yes, please attach t this frm a chrnlgical listing f all previus student prgrams yu and yur dependents have participated in, t include: begin date, departure date, status (e.g. Student, Practical Training, etc.), prgram spnsr(s), and name(s) f academic institutin(s) with legible cpies f all I-20 frms issued t yu and/r yur dependents. J Exchange Visitr Infrmatin: Have yu ever been in the U.S. n J-1 r J-2 visa status? N If yes, please attach t this frm a chrnlgical listing f all previus Exchange Visitr training, t include begin date, departure date, status (e.g. Researcher, Student, Trainee, etc.), prgram spnsr(s), and name(s) f training institutin(s) with legible cpies f all DS-2019 r IAP-66 frms issued t yu and/r yur dependents. If yes, were yu spnsred by the Educatinal Cmmissin fr Freign Medical Graduates (ECFMG)? N If yes, were/are yu subject t the 2-year hme residency requirement? N If yes, have yu applied fr a waiver f the 2-year hme residency requirement? N If yes, please explain using the space belw n what grunds did yu seek the waiver: If yes, please use the space belw t prvide the status and case number f yur waiver: Status Case Number If yes, attach t this frm a cpy f the waiver recmmendatin and/r waiver apprval. H Visa Infrmatin: Have yu ever been in the U.S. n the H classificatin (e.g. H-1B, H-4, etc.)? N If yes, please prvide the infrmatin belw detailing yur previus stay(s) in the U.S.: Year Dates yu were physically present in U.S. H Visa Status Classificatin Office f Internatinal Affairs Page 2 f 5

3 If yu were physically present in the U.S. prir t 2005 n the H classificatin, please list all perids f stay belw: If yes, and yu were in the U.S. n the H-1B visa, did yu depart the U.S. fr any length f time during the apprved perid f validity? N If yes, please use the space belw t prvide 1) dates f departure frm the U.S.; 2) dates f return t the U.S.; and 3) travel destinatin utside the U.S. (please attach a separate sheet if needed). Yu must als prvide legible cpies f any dcuments issued t yu and yur dependents as evidence f yur departure and return t the U.S. If yu answered yes t f the any questins in this sectin, yu must attach t this frm legible cpies (frnt and back) f all immigratin dcuments issued t yu and yur dependents, such as passprt shwing expiratin date and persnal infrmatin, Frm I-94, r Frm I-797. Permanent Residency Infrmatin: Have yu filed an applicatin fr permanent residency (green card) with the U.S. gvernment? N If yes, under what categry? Family Emplyment Lttery If yes, what is the status f the applicatin? If emplyment based, what categry (e.g. Outstanding, Natinal Interest, etc.)? If emplyment based, was the applicatin self petitin r emplyer petitin? Self Emplyer If emplyment based, please prvide a cpy f the USCIS receipt ntice. Have yu filed an I-485 Adjustment f Status Applicatin with the U.S. gvernment? N If yes, d yu have an Advance Parle (I-131)? N If yes, d yu have an Emplyment Authrizatin Dcument (EAD)? N If yes, please prvide cpies f all f the abve (e.g. I-485, Advance Parle, EAD) Sectin III: Dependent Infrmatin D yu currently have a spuse r unmarried child (under the age f 21) in the U.S. wh will require H-4 status? N Will yu be accmpanied by yur spuse r unmarried child (under the age f 21) wh will seek H-4 status abrad? N If yu answered yes t either f the tw preceding questins, please prvide the fllwing infrmatin: Office f Internatinal Affairs Page 3 f 5

4 Spuse Date f Birth (MM/DD/YYYY) City f Birth Cuntry f Birth Cuntry f Citizenship Cuntry f Legal Permanent Residence Has yur spuse ever been n J-1 r J-2 status? N If yes, has yur spuse been recmmended fr and/r granted a waiver f the tw-year hme residency bligatin? N If yes, please attach t this frm a cpy f the waiver recmmendatin and/r waiver apprval. Child Date f Birth (MM/DD/YYYY) City f Birth Cuntry f Birth Sn Daughter Cuntry f Citizenship Cuntry f Legal Permanent Residence Has yur child ever been n J-1 r J-2 status? N If yes, has yur child been recmmended fr and/r granted a waiver f the tw-year hme residency bligatin? N If yes, please attach t this frm a cpy f the waiver recmmendatin and/r waiver apprval. Child Date f Birth (MM/DD/YYYY) City f Birth Cuntry f Birth Sn Daughter Cuntry f Citizenship Cuntry f Legal Permanent Residence Has yur child ever been n J-1 r J-2 status? N If yes, has yur child been recmmended fr and/r granted a waiver f the tw-year hme residency bligatin? N If yes, please attach t this frm a cpy f the waiver recmmendatin and/r waiver apprval. Office f Internatinal Affairs Page 4 f 5

5 I certify under penalty f perjury that the abve infrmatin is crrect. Signature: Date: Office f Internatinal Affairs Page 5 f 5 Revised 04/01/2012 PERMANENT RESIDENT BIODATA INFORMATION FORM REVISED dcx

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