LABOR CERTIFICATION QUESTIONNAIRE

Please print this form and write or type your answers into the right column

To download a MS Word version of this document, right click on this link and select "Save Target As" (for mac users, CTRL + click).


GENERAL INFORMATION
Full Name (with last name in caps):  
U.S. Address:

  		 
Address in your home country:

  		 
Email Address:  
Home Telephone:  
Office Telephone:  
Fax number:  
Social security number:  
Date of Birth:  
Place of Birth (City, Country):  
Country of Nationality:  
Your manager's Name:  
Manager's Job Title:  
Manager's Email Address:  
Manager's Telephone Number:  
Employer's Name:  
Employer's Main Address:


  		 
Telephone:  
Your Worksite Address, if different:


  		 


INFORMATION REGARDING THE PROPOSED JOB
Job title (this is the position you will hold when you become a lawful permanent resident):  
Provide a detailed job description for this position (the job should be described broadly as to encompass the position that you will hold as a permanent resident Ð do not base the job description on current short-term projects):


  		 
Educational degree required for this position: (e.g., B.S., B.A. or M.S.):  
Required field of studies (e.g., CS, EE):  
Years of experience required for the position, if any (be realistic as excessive requirements may lead to delays and/or a denial of your case):  
Average number of hours you work per week:  
Monthly or annual salary:  
Do you supervise other workers (if yes, how many people and what are their job titles):  
Special Requirements. List particular skills and or experience that this position requires, which enables one to perform the job duties adequately (e.g., particular programming languages, certification from Microsoft, Oracle, and etc.). You can only list those skills you had attained prior to joining the sponsoring/current employer:

Special Requirements Where, when and how you attained these skills
 



 		  

 
 



 		  

 
 



 		  

 
 



 		  

 
 



 		  

 


EDUCATIONAL BACKGROUND


Beginning with the highest degree obtained, provide the dates of enrollment (mo/yr), field of study as shown in the diploma or transcripts, and address of the educational institution. DO NOT STATE "SEE ATTACHED RESUME".
Name and addresses of Colleges and Universities attended. Include trade or vocational training facilities but not include high school. Field of Study From
Month/Year 		To
Month/Year 		Degrees or Certificates Received
 

 		  

 		  

 		  

 		  

 
 

 		  

 		  

 		  

 		  

 
 

 		  

 		  

 		  

 		  

 
 

 		  

 		  

 		  

 		  

 
 

 		  

 		  

 		  

 		  

 
 

 		  

 		  

 		  

 		  

 


PREVIOUS WORK EXPERIENCE


Beginning with your current position, provide detailed information regarding work experiences during the past 10 years. Include periods of unemployment and state what you did during such periods (e.g., vacation, education, unemployment, and etc.). Please verify that all stated dates of employment, job titles and company names match your resume and all of your employment verification letters, if any. DO NOT STATE "SEE ATTACHED RESUME". This section must be completed in detail.

CURRENT EMPLOYER
Name of current Employer:  
Complete Address of Employer:


  		 
Your Job Title:  
Hours Worked per Week:  
Date Started (month & year):  
Date ended (month & year):  
Nature of Business:


  		 
Describe in detail the duties performed, including the use of tools, machines or equipment:




  		 


PREVIOUS EMPLOYER
Name of the Employer:  
Complete Address of Employer:


  		 
Your Job Title:  
Hours Worked per Week:  
Date Started (month & year):  
Date ended (month & year):  
Nature of Business:


  		 
Describe in detail the duties performed, including the use of tools, machines or equipment:




  		 

PREVIOUS EMPLOYER
Name of the Employer:  
Complete Address of Employer:


  		 
Your Job Title:  
Hours Worked per Week:  
Date Started (month & year):  
Date ended (month & year):  
Nature of Business:


  		 
Describe in detail the duties performed, including the use of tools, machines or equipment:




  		 

PREVIOUS EMPLOYER
Name of the Employer:  
Complete Address of Employer:


  		 
Your Job Title:  
Hours Worked per Week:  
Date Started (month & year):  
Date ended (month & year):  
Nature of Business:


  		 
Describe in detail the duties performed, including the use of tools, machines or equipment:




  		 

PREVIOUS EMPLOYER
Name of the Employer:  
Complete Address of Employer:


  		 
Your Job Title:  
Hours Worked per Week:  
Date Started (month & year):  
Date ended (month & year):  
Nature of Business:


  		 
Describe in detail the duties performed, including the use of tools, machines or equipment:




  		 


INFORMATION ABOUT EMPLOYEE'S FAMILY (if applicable)

Spouse
Name:  
Address:

  		 
Date & Place of Birth:
  		 

Child #1
Name:  
Address:

  		 
Date & Place of Birth:
  		 

Child #2
Name:  
Address:

  		 
Date & Place of Birth:
  		 

Child #3
Name:  
Address:

  		 
Date & Place of Birth:
  		 


Required Documents - please mail the following documents along with the completed questionnaire to us:
  • Up-to-date resume;
  • Copies of diplomas and/or transcripts from universities that you have attended;
  • Education evaluation, if available;
  • Letters from previous employer(s) confirming work experience (letters should provide dates of employment, job title and brief description of job duties, be printed on company letterhead and be signed);
  • Copy of Form I-94 (front and back) for you, your spouse and children (if applicable);
  • Copies of all passports (exclude blank pages);
  • Copies of all prior U.S. work authorization documents (e.g., H-1B approval notices, EAD, I-20s, and etc.).
  • Copy of birth certificates for you, your spouse and children (if applicable); and
  • Copy of your marriage certificate (if applicable).

    Immigration Law Group LLP
    3590 N. First St., Suite 310
    San Jose, CA 95134
    Tel (408) 432-9200
    Fax (408) 432-9191


Please answer the following questions. (If your answer is "YES" on any one of these questions, explain on a separate piece of paper.

a. Have you ever, in or outside the U.S.:
  1. knowingly committed any crime of moral turpitude or a drug-related offense for which you have not been arrested?
  2. been arrested, cited, charged, indicted, fined, or imprisoned for breaking or violating any law or ordinance, excluding traffic violations?
  3. been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency or similar action?
  4. exercised diplomatic immunity to avoid prosecution for a criminal offense in the U.S.?

___ Yes   __ No

b. Have you received public assistance in the U.S. from any source, including the U.S. government or any state, county, city, or municipality (other than emergency medical treatment), or are you likely to receive public assistance in the future?

___ Yes   __ No

c. Have you ever:
  1. within the past 10 years been a prostitute or procured anyone for prostitution, or intend to engage in such activities in the future?
  2. engaged in any unlawful commercialized vice, including, but not limited to, illegal gambling?
  3. knowingly encouraged, induced, assisted, abetted or aided any alien to try to enter the U.S. illegally?
  4. illicitly trafficked in any controlled substance, or knowingly assisted, abetted or colluded in the illicit trafficking of any controlled substance?

___ Yes   __ No

d. Have you ever engaged in, conspired to engage in, or do you intend to engage in, or have you ever solicited membership or funds for, or have you through any means ever assisted or provided any type of material support to, any person or organization that has ever engaged or conspired to engage, in sabotage, kidnapping, political assassination, hijacking, or any other form of terrorist activity?

___ Yes   __ No

e. Do you intend to engage in the U.S. in:
  1. espionage?
  2. any activity a purpose of which is opposition to, or the control or overthrow of, the Government of the U.S., by force, violence or other unlawful means?
  3. any activity to violate or evade any law prohibiting the export from the Untied States of goods, technology or sensitive information?

___ Yes   __ No

f. Have you ever been a member of, or in any way affiliated with, the Communist Party or any other totalitarian party?

___ Yes   __ No

g. Did you, during the period March 23, 1933 to May 8, 1945, in association with either the Nazi Government of Germany or any organization or government associated or allied with the Nazi Government of Germany, ever order, incite, assist or otherwise participate in the persecution of any person because of race, religion, nationality, ethnic origin, or political opinion?

___ Yes   __ No

h. Have you ever engaged in genocide, or otherwise ordered, incited, assisted or otherwise participated in the killing of any person because of race, religion, nationality, ethnic origin, or political opinion?

___ Yes   __ No

i. Have you ever been deported from the U.S., or removed from the U.S. at government expense, excluded within the past year, or are you now in exclusion or deportation proceedings?

___ Yes   __ No

j. Are you under a final order of civil penalty of violating section 274C of the Immigration Act for use of fraudulent documents, or have you by fraud or willful misrepresentation of a material fact, ever sought to procure, or procured, a visa, other documentation, entry into the U.S., or any other immigration benefit?

___ Yes   __ No

k. Have you ever left the U.S. to avoid being drafted into the U.S. Armed Forces?

___ Yes   __ No

l. Have you ever been a J non-immigrant exchange visitor who was subject to the 2 year foreign residence requirement and not yet complied with that requirement or obtained a waiver?

___ Yes   __ No

m. Are you now withholding custody of a U.S. Citizen child outside the U.S. from a person granted custody of the child?

___ Yes   __ No

n. Do you plan to practice polygamy in the U.S.?

___ Yes   __ No