H-1B DEPARTMENT VISA REQUEST FORM - BENEFICIARY
To be completed by H-1B applicant. Please answer the following questions regarding the application of
your H-1B visa.
1. Researcher/Scholar Information: (Please Print)
Last/Family Name
First Name
Middle Name
All other names used (include maiden name and names from all previous marriages)
____________________________________________________________________________
Date of Birth (MM/DD/YEAR) Click here to enter text. Gender: Male _____Female
US. Social Security Number Click here to enter text.
(If you have a U.S. Social Security Number, please provide copy of card.)
A # (if any)Click here to enter text.
Country of Birth Click here to enter text.
Province of Birth Click here to enter text.
Country of Citizenship Click here to enter text.
Phone number Click here to enter text.
E-mail Address Click here to enter text.
2. You are requesting: (Click one)
_____ New Employment (including new employer filing H-1B extension.)
_____ Continuation of previously approved employment without change with same employer.
_____ Change in previously approved employment.
_____ New concurrent employment.
_____ Change of employer.
3. If currently in the United States complete the following:
Date of Last Arrival (MM/DD/YEAR) Click here to enter text.
Place of last entrance (City & State) Click here to enter text.
I-94 # (Arrival/Departure Document) Click here to enter text.
(Provide copy of front and back of card)
Current Nonimmigrant Status_________________________________________________
Date Status Expires (MM/DD/YEAR) __________________________________________
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H-1B DEPARTMENT VISA REQUEST FORM - BENEFICIARY
Passport and Expiration Page (Provide copy) _____________________________________
Passport Number_____________________________________________________
Date Passport Issued (MM/DD/YEAR) ___________________________________
Date Passport Expires (MM/DD/YEAR) __________________________________
Current U.S. address:
_______________________________________________________
_______________________________________________________
_______________________________________________________
4. Please indicate the U.S. Consulate or inspection facility you want notified if this petition is
approved. Choose the U.S. Consulate from the list at this website http://www.usembassy.gov/
.
_______________________________________________________
_______________________________________________________
Your Address if currently outside the United States, your foreign address:
_______________________________________________________
_______________________________________________________
_______________________________________________________
5. Have you ever applied for H-1B status in the past and been denied?
Yes
No
If yes, explain____________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
6. Have you ever been granted H-1B status in the past?
Yes
No______
If yes, what were the dates of your approved H-1B status? _________________________
Please provide a copy of your H-1B Approval Notices.
Where did you work as an H-1B? ______________________________________________
7. Have you any other application pending that relates to you immigration status?
Yes
No
If yes, explain__________________________________________________________
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H-1B DEPARTMENT VISA REQUEST FORM - BENEFICIARY
_________________________________________________________________________
8. Does each person in this petition have a valid passport?
Yes
No
9. List any dependents who will apply for an H-4 visa with this petition including:
a. Dependent’s name__________________________________________________
b. Relationship to Beneficiary ___________Spouse
____________________Child
c. Dependent’s country of citizenship_____________________________________
d. If dependent is currently in the United States, current dependent visa type ______
a. Dependent’s name___________________________________________________
b. Relationship to Beneficiary ___________Spouse _____________________Child
c. Dependent’s country of citizenship______________________________________
d. If dependent is currently in the United States, current dependent visa type_______
10. Is any person involved in this petition in removal proceedings?
Yes
No
If yes, explain: ________________________________________________________
_________________________________________________________
11. Are you or any dependents applying for a replacement/initial 1-94 with this petition?
Yes
No
12. Are you or any dependents currently in exclusion or deportation proceedings?
Yes
No
If yes, explain ________________________________________________________
____________________________________________________________________
13. Are you subject to any bar that would prevent you from changing status to or entering?
The United States on an H-1B visa (such as 212e for J-1 visa holders?)
Yes
No
If yes, explain:
14. Have you ever applied for an immigration petition?
If yes, explain
Yes
No
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H-1B DEPARTMENT VISA REQUEST FORM - BENEFICIARY
15. Have you ever filed for Permanent Residency?
Yes
No
16. Did you received a master’s degree or higher degree from a U.S. Institution of Higher
Education?
Yes
No
17. If yes, name and mailing address of the U.S. Institution of Higher Education.
______________________________________________
Signature of H-1B Applicant
Date
RETURN FORM TO:
Employee Immigration Services
Human Resources
The University of Akron
185 East Mill Street
Akron, Ohio 44325-4733
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