Form I-526 04/15/19
Page 1 of 13
For
USCIS
Use
Only
Immigrant Petition by Alien Entrepreneur
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form I-526
OMB No. 1615-0026
Expires 04/30/2021
START HERE - Type or print in black ink.
Part 1. Information About You
Alien Registration Number (A-Number) (if any)
Your Full Name
4.a. Family Name
(Last Name)
4.b. Given Name
(First Name)
4.c.
Middle Name
1.
Street Number
and Name
Mailing Address
7.a.
In Care Of Name (if any)
7.b.
7.c.
7.d. City or Town
7.h.
Postal Code
7.i. Country
7.e.
State
7.f.
ZIP Code
USCIS Online Account Number (if any)2.
7.g.
Province
A-
Apt. Ste. Flr.
Provide the following information about yourself.
U.S. Social Security Number (if any)3.
Other Names Used
List all other names you have ever used, including aliases,
maiden name, and nicknames. If you need extra space to
complete this section, use the space provided in Part 11.
Additional Information.
5.a. Family Name
(Last Name)
6.a. Family Name
(Last Name)
6.b. Given Name
(First Name)
6.c.
Middle Name
Fee Receipt
Action BlockClassification
Resubmitted
Received
Priority Date
Relocated
Sent
Received
5.b. Given Name
(First Name)
5.c.
Middle Name
Remarks
Select this box if Form G-28 is
attached to represent the
applicant.
Attorney or Accredited Representative
USCIS Online Account Number (if any)
To be completed by an attorney or
BIA-accredited representative (if any).
(USPS ZIP Code Lookup)
Form I-526 04/15/19
Page 2 of 13
Part 1. Information About You (continued)
Physical Address
9.a. Street Number
and Name
9.b.
Provide your physical addresses for the last five years. Provide
your present address first. If you need extra space to complete
this section, use the space provided in Part 11. Additional
Information.
Apt. Ste.
Flr.
9.c. City or Town
9.d.
State
9.e.
ZIP Code
Country 9.h.
Postal Code
9.g.
Province
9.f.
9.i.
9.j.
Present
10.a. Street Number
and Name
10.b. Apt. Ste. Flr.
10.c. City or Town
10.d.
State
10.e.
ZIP Code
Country 10.h.
Postal Code 10.g.
Province
10.f.
10.i.
10.j.
Country 11.h.
Postal Code 11.g.
11.i. From (mm/dd/yyyy)
11.j. To (mm/dd/yyyy)
12.a. Street Number
and Name
12.b. Apt. Ste. Flr.
12.c. City or Town
12.d.
State
12.e.
ZIP Code
Country 12.h.
Postal Code 12.g.
Province
12.f.
12.i.
12.j.
13.a. Street Number
and Name
13.b. Apt. Ste. Flr.
13.c. City or Town
13.d.
State
13.e.
ZIP Code
Country 13.h.
Postal Code 13.g.
Province
13.f.
13.i.
13.j.
11.a. Street Number
and Name
11.b. Apt. Ste. Flr.
11.c. City or Town
11.d.
State
11.e.
ZIP Code
Province
11.f.
If you answered "No" to Item Number 8., provide your
physical address in Item Numbers 9.a. - 9.h.
8. Is your current mailing address the same as your physical
address?
Yes No
From (mm/dd/yyyy)
To (mm/dd/yyyy)
From (mm/dd/yyyy)
To (mm/dd/yyyy)
From (mm/dd/yyyy)
To (mm/dd/yyyy)
From (mm/dd/yyyy)
To (mm/dd/yyyy)
Form I-526 04/15/19
Page 3 of 13
Employment History
Part 1. Information About You (continued)
Provide your employment history for the last five years. (If
none, so state.) List present employment first. If you need
extra space to complete this section, use the space provided in
Part 11. Additional Information.
Employer Name14.a.
14.b. Street Number
and Name
14.c. Apt. Ste. Flr.
14.d. City or Town
14.e.
State
14.f.
ZIP Code
Country 14.i.
Postal Code
14.h.
Province14.g.
Job Title14.j.
14.k.
14.l.
Employer Name15.a.
15.b. Street Number
and Name
15.c. Apt. Ste. Flr.
15.d. City or Town
15.e.
State
15.f.
ZIP Code
Country 15.i.
Postal Code 15.h.
Province15.g.
Job Title15.j.
Employer Name16.a.
16.b. Street Number
and Name
16.c. Apt. Ste. Flr.
16.d. City or Town
16.e.
State
16.f.
ZIP Code
Country 16.i.
Postal Code
16.h.
Province16.g.
Job Title16.j.
16.k.
16.l.
Employer Name17.a.
17.b. Street Number
and Name
17.c. Apt. Ste. Flr.
17.d. City or Town
17.e.
State
17.f.
ZIP Code
Country 17.i.
Postal Code
17.h.
Province17.g.
Job Title17.j.
17.k.
17.l.
From (mm/dd/yyyy)
To (mm/dd/yyyy)
From (mm/dd/yyyy)
To (mm/dd/yyyy)
From (mm/dd/yyyy)
To (mm/dd/yyyy)
15.k.
15.l.
From (mm/dd/yyyy)
To (mm/dd/yyyy)
Form I-526 04/15/19
Page 4 of 13
Part 1. Information About You (continued)
Employer Name18.a.
18.b. Street Number
and Name
18.c.
Apt. Ste. Flr.
18.d. City or Town
18.e.
State
18.f.
ZIP Code
Country 18.i.
Postal Code
18.h.
Province18.g.
Job Title18.j.
18.k.
18.l.
Other Information About You
21.
20.
City or Town of Birth
State or Province of Birth
22.
Sex
Male Female
Place of Birth
Country of Birth
23.
NOTE: If you are a citizen of more than one country or your
nationality differs from your citizenship, provide the
information in Part 11. Additional Information.
Country of Citizenship or Nationality
24.
Place of Arrival or Port-of-Entry
27.a. City or Town
27.b.
State
Date Period of Authorized Stay Expires/Expired
(mm/dd/yyyy)
28.b.
Passport Number28.c.
Travel Document Number28.d.
I-94 Arrival-Departure Record Number28.a.
Date Passport or Travel Document Expires (mm/dd/yyyy)28.f.
Country That Issued Passport or Travel Document 28.e.
Current Nonimmigrant Status (if applicable)28.g.
Date Current Nonimmigrant Status Expires (mm/dd/yyyy)
28.h.
Part 2. Information About Your Investment
Regional Center (if any)
1. Is your investment associated with an approved Regional
Center?
NoYes
2. Regional Center Name
3.
Regional Center Identification Number
4.
What is the receipt number for the approved Regional
Center application upon which your petition is based?
5.
If applicable, provide the New Commercial Enterprise
(NCE) Identification Number.
Date of Birth (mm/dd/yyyy)
19.
Date of Arrival (mm/dd/yyyy)
26.
Your Entry Into the United States
From (mm/dd/yyyy)
To (mm/dd/yyyy)
Country of Last Foreign Residence
25.
Form I-526 04/15/19
Page 5 of 13
Is the job-creating-entity (JCE) principally doing business
in a targeted employment area?
Is the new commercial enterprise (NCE) principally doing
business in a targeted employment area?
Part 2. Information About Your Investment
(continued)
Select the appropriate box to indicate the type of petition you
are filing. If you select Item Number 6., provide the requested
information.
Targeted Employment Area (TEA)6.
Petition Type and Required Capital Investment
This petition is based on an investment in a targeted
employment area for which the required investment
amount of capital has been adjusted downward.
a.
Is the area a rural area?b. NoYes
Is the area a high unemployment area?
c.
NoYes
Address Where the NCE is Principally Doing Business
d.
e.
Is the area a rural area?
f.
NoYes
Is the area a high unemployment area?g.
NoYes
Address where the JCE is principally doing business
h.
Composition of Your Investment and Your Income
Composition of Investment
Total Amount Deposited or Committed to Deposit into
U.S. Business Accounts for NCE
9.
Total Value of Assets Purchased for Use in NCE10.
Total Value of All Property Transferred From Abroad
for Use in NCE
11.
12. Total of All Debt Financing
13. Total Stock or Other Equity Purchases
14. Other Capital
Your Income
15. Your Gross Income at Time of Investment
16. Your Net Income at Time of Investment
17. Your Current Gross Income
18. Your Current Net Income
Your Net Worth
19. Your Net Worth at Time of Investment
20.
Your Current Net Worth
Upward Adjustment Area 7.
This petition is based on an investment in an area for
which the required investment amount of capital has been
adjusted upward.
Non-TEA/Non-Upward Adjustment Area8.
This petition is based on an investment in an area that is
neither a targeted employment area nor an upward
adjustment area.
Street Number
and Name
City or Town
State ZIP Code
County
Street Number
and Name
Apt. Ste. Flr.
City or Town
State ZIP Code
County
$
$
$
$
$
$
$
$
$
$
$
$
NoYes
NoYes
Flr.Ste.Apt.
Form I-526 04/15/19
Page 6 of 13
Part 2. Information About Your Investment
(continued)
Your Sources of Investment Capital
Please identify the sources of the capital you have invested or
are actively in the process of investing into the NCE. (Select all
that apply.)
Income
Other
In the space below, describe the documentation included
with this petition to demonstrate that the capital you have
invested or are actively in the process of investing was
obtained through lawful means.
Part 3. Information About the New Commercial
Enterprise (NCE)
Type of NCE (Select only one)
NCE formed after November 29, 19901.a.
NCE resulting from the purchase of a business
formed on or before November 29, 1990 that is
restructured or reorganized
1.b.
NCE resulting from a capital investment in and
substantial expansion of a business formed on or
before November 29, 1990.
1.c.
Additional Information About the NCE
2. Name of NCE (Required Field - Do Not Leave Blank)
3.a. Street Number
and Name
3.b. Apt. Ste. Flr.
3.c. City or Town
3.e. State 3.f. ZIP Code
4.
Telephone Number of NCE
5.
Type of Entity (for example, corporation, limited liability
company, partnership)
County3.d.
Nature of Activity (for example, furniture manufacturer)
6.
7.
Included Industries (provide North American Industry
Classification System (NAICS) codes)
Have you invested or are you actively in the process of
investing in a troubled business?
8.
NoYes
NOTE: If you answered "Yes" to Item Number 8., you must
provide an explanation in Part 11. Additional Information of
how the NCE qualifies as a troubled business.
10.
Federal Employer Identification Number
Date NCE Formed (mm/dd/yyyy)
9.
Date of Your Initial Investment (mm/dd/yyyy)
11.
$
Amount of Your Initial Investment in the NCE12.
$
Your Total Capital Investment in the NCE To Date 13.
Address of NCE
What percentage of the NCE do you own?14. %
Indebtedness (Loan, Loan Proceeds, Promissory
Note, etc.)
Gift (including capital obtained through inheritance)
Tangible Assets (Equipment, Inventory, etc.)
21.a.
21.b.
21.c.
21.d.
21.e.
21.f.
Form I-526 04/15/19
Page 7 of 13
Is the JCE different from the NCE?
Part 3. Information About the New Commercial
Enterprise (NCE) (continued)
Multiple Investors. If you are not the sole investor in the
NCE, list the name of any other person or entity (for example, a
corporation, limited liability company, partnership, etc.) that
holds a percentage ownership of the NCE. Also indicate the
percentage of ownership and whether any of these persons
obtained classification as an alien entrepreneur under INA
section 203(b)(5) on the basis of his or her investment in this
NCE or is seeking classification as an alien entrepreneur under
INA section 203(b)(5). If you need additional space, provide
the information in Part 11. Additional Information.
Name of Party
15.a.
Percentage of Ownership15.b. %
No
Is the party seeking classification as an alien entrepreneur
under INA Section 203(b)(5) or has the party obtained
classification as an alien entrepreneur under INA section
203(b)(5) on the basis of his or her investment in this NCE?
Yes
15.c.
Name of Party
16.a.
Percentage of Ownership16.b. %
No
Is the party seeking classification as an alien entrepreneur
under INA section 203(b)(5) or has the party obtained
classification as an alien entrepreneur under INA section
203(b)(5) on the basis of his or her investment in this NCE?
Yes
16.c.
Part 4. Information About the Job-Creating
Entity (JCE) (if different from the NCE)
1.
Name of the JCE
2.
4.
Telephone Number of JCE (with area code)
Nature of Activity (for example, furniture manufacturer)
6.
7.
Included Industries (provide North American Industry
Classification System (NAICS) codes)
Multiple Job-Creating Entities. If there is more than one JCE
involved in the project, provide information regarding all JCE's
involved with the new commercial enterprise. If you need
additional space, use the space provided in Part 11. Additional
Information.
Name of Additional Job-Creating Entity
8.
9.a. Street Number
and Name
9.b. Apt. Ste. Flr.
9.c. City or Town
9.e.
State
9.f.
ZIP Code
County9.d.
10. Telephone Number of Job-Creating Entity (with area code)
Type of Entity (for example, corporation, limited liability
company, partnership)
11.
Nature of Activity (for example, furniture manufacturer)
12.
13.
Included Industries (provide North American Industry
Classification System (NAICS) codes)
3.a. Street Number
and Name
3.b. Apt. Ste. Flr.
3.c. City or Town
County3.d.
3.e.
State
3.f.
ZIP Code
Name of Party
17.a.
Percentage of Ownership17.b. %
Is the party seeking classification as an alien entrepreneur
under INA section 203(b)(5) or has the party obtained
classification as an alien entrepreneur under INA section
203(b)(5) on the basis of his or her investment in this NCE?
17.c.
Type of Entity (for example, corporation, limited liability
company, partnership)
5.
Yes No
NoYes
Form I-526 04/15/19
Page 8 of 13
$
What is your current salary in the NCE?3.
$
What are the costs for benefits you receive in your current
position in the NCE?
4.
Number of Full-Time Direct and Qualifying Employees
in the NCE at the Time of Your Initial Investment
5.
Current Number of Full-Time Direct and Qualifying
Employees in the NCE
6.
Difference in Number of Full-Time Direct and Qualifying
Employees
7.
Estimated Number of Full-Time Direct and Indirect
Positions That Will Be Created During the Relevant Time
Period
8.
If the new commercial enterprise is associated with a
Regional Center, does this petition rely on indirect job
creation?
9.
NoYes
NOTE: If you answered "Yes" to Item Number 9.,
indicate the economic model used to estimate indirect
job creation in Part 11. Additional Information.
$
Total Amount of Your Capital That Has Been or Will Be
Made Available to the JCE
10.
$
Total Amount of Capital Derived From Investors Who
Have Not Sought and Are Not Seeking Classification As
Alien Entrepreneurs
11.
Country of Current Residence
1.c.
Country of Last Permanent Residence Abroad2.b.
4. Telephone Number
If your native alphabet is other than Roman letters, type or print
the foreign address in your native alphabet, below.
3.c. City or Town
Street Number
and Name
3.a.
3.b.
3.d.
Postal Code
3.e.
3.f. Country
Apt. Ste. Flr.
Province
5.c. City or Town
Street Number
and Name
5.a.
5.b.
5.d.
Postal Code
5.e.
5.f. Country
Apt. Ste. Flr.
Province
Part 5. Employment Creation Information
1.
What is your position, office, or title with the NCE?
What are your duties, activities, and responsibilities in the
NCE?
2.
NOTE: If you need additional space, provide the information
in Part 11. Additional Information.
Address in Country of Last Permanent Residence
Abroad
Part 6. Processing Information
Select the appropriate box to indicate how you will seek lawful
permanent resident status.
Country of Citizenship or Nationality
1.b.
1.a.
2.a.
Immigrant Visa Processing
Application for Adjustment of Status
Form I-526 04/15/19
Page 9 of 13
Are you currently subject to a final order of exclusion,
deportation, or removal, or subject to reinstatement of
such an order?
Are you currently in immigration proceedings before the
Department of Homeland Security (DHS) or Department
of Justice (DOJ)?
Exclusion
Type of Proceedings (Select only one)
Deportation
Removal
8.a.
8.b.
City or Town
NoYes
9.
Part 6. Processing Information (continued)
7.a.
7.b.
7.c.
Immigration Proceedings
Please indicate whether you are in exclusion, deportation, or
removal proceedings before the Department of Homeland
Security (DHS) or the Department of Justice's (DOJ), Executive
Office for Immigration Review (EOIR) Immigration Court or
Board of Immigration Appeals. You also must provide an
explanation for why are you in proceedings in Part 11.
Additional Information.
NoYes
6.
Location of Proceedings
State
Have you ever worked in the United States without
permission?
Employment in the United States
NoYes
10.
11. If you answered "Yes" to Item Number 10., provide an
explanation below. If you need additional space, use
Part 11. Additional Information.
Part 7. Information on Petitioner's Spouse and
Children
List your spouse and all of your children. Also, note if the
individual will be applying for a visa abroad or for adjustment
of status as your dependent. If you need additional space to list
other children, use Part 11. Additional Information.
Family Member 1
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c.
Middle Name
Applying for Adjustment of Status?
5.
NoYes
Applying for Visa Abroad?
6.
NoYes
4. Relationship to You
3. Country of Birth
2. Date of Birth (mm/dd/yyyy)
Family Member 2
7.a. Family Name
(Last Name)
7.b. Given Name
(First Name)
7.c.
Middle Name
8. Date of Birth (mm/dd/yyyy)
9. Country of Birth
10. Relationship to You
Applying for Adjustment of Status?
11.
NoYes
Applying for Visa Abroad?
12.
NoYes
Family Member 3
13.a. Family Name
(Last Name)
13.b. Given Name
(First Name)
13.c.
Middle Name
Form I-526 04/15/19
Page 10 of 13
14. Date of Birth (mm/dd/yyyy)
15. Country of Birth
16. Relationship to You
Applying for Adjustment of Status?
17.
NoYes
Applying for Visa Abroad?
18.
NoYes
Part 7. Information on Petitioner's Spouse and
Children (continued)
Family Member 3 (continued)
20. Date of Birth (mm/dd/yyyy)
21. Country of Birth
22. Relationship to You
Applying for Adjustment of Status?
23.
NoYes
Applying for Visa Abroad?
24.
NoYes
Family Member 4
19.a. Family Name
(Last Name)
19.b. Given Name
(First Name)
19.c.
Middle Name
Family Member 5
25.a. Family Name
(Last Name)
25.b. Given Name
(First Name)
25.c.
Middle Name
26. Date of Birth (mm/dd/yyyy)
27. Country of Birth
28. Relationship to You
Applying for Adjustment of Status?
29.
NoYes
Applying for Visa Abroad?
30.
NoYes
Family Member 6
31.a. Family Name
(Last Name)
31.b. Given Name
(First Name)
31.c.
Middle Name
32. Date of Birth (mm/dd/yyyy)
33. Country of Birth
34. Relationship to You
Applying for Adjustment of Status?
35.
NoYes
Applying for Visa Abroad?
36.
NoYes
Part 8. Statement, Contact Information,
Declaration, Certification, and Signature of the
Petitioner or Authorized Signatory
NOTE: Read the Penalties section of the Form I-526
Instructions before completing this part.
NOTE: Select the box for either Item 1.a. or 1.b. If
applicable, select the box for Item Number 2.
Petitioner's or Authorized Signatory's Statement
1.a.
I can read and understand English, and I have read
and understand every question and instruction on this
petition and my answer to every question.
1.b.
The interpreter named in Part 9. read to me every
question and instruction on this petition and my
answer to every question in
in which I am fluent. I understood all of this
information as interpreted.
, a language
2.
At my request, the preparer named in Part 10.,
prepared this petition for me based only upon
information I provided or authorized.
Authorized Signatory's Contact Information
Authorized Signatory's Given Name (First Name)3.b.
Authorized Signatory's Family Name (Last Name)3.a.
Form I-526 04/15/19
Page 11 of 13
Authorized Signatory's Title4.
5. Authorized Signatory's Daytime Telephone Number
Authorized Signatory's Email Address (if any)7.
6.
Authorized Signatory's Mobile Telephone Number (if any)
Part 8. Statement, Contact Information,
Declaration, Certification, and Signature of the
Petitioner or Authorized Signatory (continued)
Petitioner's or Authorized Signatory's Declaration
and Certification
Copies of any documents submitted are exact photocopies of
unaltered, original documents, and I understand that, as the
petitioner, I may be required to submit original documents to
USCIS at a later date.
I authorize the release of any information from my records, or
from the petitioning organization's records, to USCIS or other
entities and persons where necessary to determine eligibility for
the immigration benefit sought or where authorized by law. I
recognize the authority of USCIS to conduct audits of this
petition using publicly available open source information. I
also recognize that any supporting evidence submitted in
support of this petition may be verified by USCIS through any
means determined appropriate by USCIS, including but not
limited to, on-site compliance reviews.
If filing this petition on behalf of an organization, I certify that I
am authorized to do so by the organization.
I certify, under penalty of perjury, that I have reviewed this
petition, I understand all of the information contained in, and
submitted with, my petition, and all of this information is
complete, true, and correct.
Petitioner's or Authorized Signatory's Signature
Date of Signature (mm/dd/yyyy)8.b.
Petitioner's Signature (sign in ink)8.a.
NOTE TO ALL PETITIONERS AND AUTHORIZED
SIGNATORIES: If you do not completely fill out this petition
or fail to submit required documents listed in the Instructions,
USCIS may delay a decision on or deny your petition.
Part 9. Interpreter's Contact Information,
Certification, and Signature
Provide the following information about the interpreter.
Interpreter's Full Name
Interpreter's Family Name (Last Name)1.a.
Interpreter's Given Name (First Name)1.b.
Interpreter's Business or Organization Name (if any)2.
3.h.
Interpreter's Mailing Address
3.c. City or Town
3.d. State 3.e. ZIP Code
3.f. Province
Street Number
and Name
3.a.
Country
3.b.
3.g. Postal Code
Apt. Ste. Flr.
Interpreter's Contact Information
Interpreter's Daytime Telephone Number4.
Interpreter's Email Address (if any)6.
Interpreter's Mobile Telephone Number (if any)5.
Interpreter's Certification
I certify, under penalty of perjury, that:
I am fluent in English and
,
which is the same language specified in Part 8., Item 1.b., and I
have read to this petitioner or the authorized signatory in the
identified language every question and instruction on this petition
and his or her answer to every question. The petitioner or
authorized signatory informed me that he or she understands
every instruction, question, and answer on the petition, including
the Petitioner's or Authorized Signatory's Declaration and
Certification, and has verified the accuracy of every answer.
Form I-526 04/15/19
Page 12 of 13
Date of Signature (mm/dd/yyyy)7.b.
Interpreter's Signature (sign in ink)7.a.
Interpreter's Signature
Part 9. Interpreter's Contact Information,
Certification, and Signature (continued)
Part 10. Contact Information, Declaration, and
Signature of the Person Preparing this Petition,
if Other Than the Petitioner
Preparer's Full Name
1.a.
Preparer's Family Name (Last Name)
Preparer's Given Name (First Name)
1.b.
Provide the following information about the preparer.
Preparer's Business or Organization Name (if any)2.
I am not an attorney or accredited representative but
have prepared this petition on behalf of the petitioner
and with the petitioner's consent.
7.a.
7.b.
Preparer's Statement
I am an attorney or accredited representative and my
representation of the petitioner in this case
does not extend beyond the
preparation of this petition.
NOTE: If you are an attorney or accredited
representative, you may be obliged to submit a
completed Form G-28, Notice of Entry of Appearance
as Attorney or Accredited Representative, with this
petition.
extends
3.h.
3.f.
Province
Country
3.g. Postal Code
Preparer's Mailing Address
3.c. City or Town
3.d. State 3.e. ZIP Code
Street Number
and Name
3.a.
3.b. Apt. Ste. Flr.
Preparer's Certification
8.a. Preparer's Signature (sign in ink)
8.b. Date of Signature (mm/dd/yyyy)
By my signature, I certify, under penalty of perjury, that I
prepared this petition at the request of the petitioner or authorized
signatory. The petitioner has reviewed this completed petition,
including the Petitioner's or Authorized Signatory's
Declaration and Certification, and informed me that all of this
information in the form and in the supporting documents is
complete, true, and correct.
Preparer's Signature
Preparer's Contact Information
4. Preparer's Daytime Telephone Number
6. Preparer's Email Address (if any)
5. Preparer's Mobile Telephone Number (if any)
Form I-526 04/15/19
Page 13 of 13
3.d.
6.a.
Page Number 6.b. Part Number 6.c. Item Number
6.d.
5.d.
Part 11. Additional Information
If you need extra space to provide any additional information
within this petition, use the space below. If you need more
space than what is provided, you may make copies of this page
to complete and file with this petition or attach a separate sheet
of paper. Type or print your name and A-Number (if any) at the
top of each sheet, indicate the Page Number, Part Number,
and Item Number to which your answer refers, and sign and
date each sheet.
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
2. A-Number (if any)
3.a. Page Number
3.b. Part Number 3.c. Item Number
5.a.
Page Number 5.b. Part Number 5.c. Item Number
A-
4.a.
Page Number 4.b. Part Number 4.c. Item Number
4.d.
7.a.
Page Number 7.b. Part Number 7.c. Item Number
7.d.