Name:**

Gender (select one):
   Male
   Female

Other Names Used or Aliases (i.e. maiden name):

Full Name in Native Alphabet:

Social Security #:

A#:

Address:

Telephone Number:*

Fax Number:

Email address*

What is your current occupation?

English Language (select one):
   Need Translator
   Conversational
   Fluent

Applicants Living in the United States

U.S. Address:

Address:

Date of Arrival:
// (mm/dd/yyyy)

Type of Visa:

I-94 #:

Current Non-Immigrant Status:

Expires on:
// (mm/dd/yyyy)

General Immigration Questions

Are you currently a green card holder?
   Yes
   No

If yes when does it expire?
// (mm/dd/yyyy)

Have you previously held a US tourist or business visa (a B1 or B2 visa)?
   Yes
   No

If yes, what type of visa?

If yes, when was your last date of entry?
// (mm/dd/yyyy)

Have you previously applied for a US immigrant or non-immigrant visa and been denied?
   Yes
   No

If yes, please provide details why application was denied.

Are there any children listed on the preliminary questionnaire that will turn 21 within the next year?
   Yes
   No

If yes, please provide name and date of birth of child.
// (mm/dd/yyyy)

Is there any other relevant information regarding your current immigration that we should be aware of for you or any member of your family? (please provide details below)

Primary Applicant's Net Worth

Please complete all sections below to the best of your ability so that we can evaluate the best funds to be used for immigration purposes. Also please note where the funds originated from under source of funds, i.e. checking account $250,000 business income; savings account $50,000 sale of boat.

Qualifying investors currently in the US on a non-immigrant visa need to be accredited investors. An accredited investor is a term defined by various security laws that describes investors permitted to invest in certain types of higher risk investments, limited partnerships, hedge funds and angel investor networks. In the US an individual is considered to be an accredited investor if he or she has a net worth of at least US$1 million or has made at least US$200,000 each year for the last two years (US$300,000 with spouse if married) and has the expectation to make the same amount in the current year.

Please provide information for assets totaling US$1 million or more

Location of assets:
   United States
   Abroad
   Both

If abroad, which country or countries?

* please note, if asset is a gift, source of funds for the gift needs to be explained. i.e. gift from parents of $250,000, source of funds sale of parent's real estate.
** please note, we only accept loans made from a bank or other lending institutions such as home equity lines of credit.

Source Of Funds For Investment

please be as specific as possible when completing the information below.

of the above assets, which will contribute to the investment?

Additional Information Requested

Have you retained an immigration attorney?
   Yes
   No

If so, please provide contact information for our files

If not, do you need a referral?
   Yes
   No

How did you hear about Oregon D-Force Regional Center and our programs?

Were you referred to us by someone?
   Yes
   No

If yes, please provide name and contact information for our files