Register Account

First Name

Middle Name

Last Name

Date of Birth

Do you have any temporary or permanent civil protection order or restraining order issued against you?

Yes No

If yes, Please provide details of such order including date, city and state

Any arrest or conviction of the client or person for homicide, murder, manslaughter, assault, battery, domestic violence, rape, sexual assault, abusive sexual contact, sexual exploitation, incest, child abuse or neglect, torture, trafficking, peonage, holding hostage, involuntary servitude, slave trade, kidnapping, abduction, unlawful criminal restraint, false imprisonment, stalking, or any similar activity in violation of Federal, State or local criminal law?

Yes No

If yes, please provide details

Have you ever had any Federal, State, or local arrest or conviction for offenses related to controlled substances or alcohol?

Yes No

If yes, please provide details

Are you currently married?

Yes No

Have you ever been married?

Yes No

If yes please indicate how many times you have been married, when and where you were previously married, when and where previous marriages were dissolved?

Have you previously sponsored a foreign fiancée to whom you were engaged or married?

Yes No

If yes please provide details

Do you have any children who are under the age of 18?

Yes No

If yes please list how many and ages of children

List all States and countries in which you have resided since the age of 18

I confirm that all the information above is true and correct