Fillable Ins Form I-643 (Visa Pro)

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Ins Form I-643 (Visa Pro)

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The Ins Form I-643 (Visa Pro) form is 1 page long and contains:

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  • 71 check-boxes
  • 94 other fields

Country of origin: US
File type: PDF

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Department of Homeland Security
U.S. Citizenship and Immigration Services
OMB No: 1615-0070; Expires 01/31/2015
I-643, Health and Human Services Statistical
Data for Refugee/Asylee Adjusting Status
Print or type in blue or black ink.
Alien Registration Number:
Middle
First (Given)
Last (Family)
Telephone Number (with area code)
Current Address:
(Zip Code)
(State)
(City)
(Number, Street, and Apartment No.)
2. My three most recent cities of residence in the United States have been:
(List most recent first)
State
From (mm/dd/yyyy)
To (mm/dd/yyyy)
Present
Alien Number
(Self)
(Self)
4. My employment since entering the United States has been:
(List most recent first)
Check One
Company Name
Job Title
My major occupation or profession before coming to the United States was:
5. My education before coming to the United States was:
(Check all that apply)
Grades 1-8
Some university
My knowledge of English was acquired by: (Check all that apply)
Some high school
University diploma
Use in another country
Training in the U.S.
High school diploma
Graduate studies
Use in the U.S.
Training in refugee camp
Technical school
Professional training
Other (Please explain):
Training in another country
Technical school certificate
Graduate degree
7. English Language Skills:
6. I have had the following training or education in the U.S.
(Check one)
Course of Study
College
Technical/Vocational
Other (specify):
8. Since in the United States, list as many types of public assistance (excluding emergency medical treatment) that you have received
or someone has received on your behalf. Please include public assistance received from the U.S. Government or any State,
county, city, or municipality.
Public Assistance
From (mm/yyyy)
To (mm/yyyy)
Public Assistance
From (mm/yyyy)
To (mm/yyyy)
Medical assistance
Other (specify):
City or Town
Food Stamps
SSI
(Check all that apply)
Cash assistance (Welfare)
Date of Birth (mm/dd/yyyy)
Today's Date: (mm/dd/yyyy)
Form I-643 (01/08/13) Y Page 1
A -
Type of Training/Education
Fair
(Please use another sheet(s) if needed)
Country of Birth:
Country of Citizenship/Nationality:
Native Language:
Name
Relationship
to Me
Gender
M/F
Date of Birth
(mm/dd/yyyy)
Country of
Birth
Location
City, State
From
(mm/dd/yyyy)
To
(mm/dd/yyyy)
Wage Per
Hour
Currently Employed?
Yes No
Attending School?
Yes No
Part
Time
Full
Time
Speaking
High School
Check If
Still Attending
Check If
Completed
3. There are
members of the household,
of whom are employed.
Social Security Number:
Cellphone Number (with area code)
A Few Words
Good
None
Reading
Good
Fair
A Few Words
None
Writing
None
Good
Fair
A Few Words
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Ins Form I-643 (Visa Pro)

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Completed 18 July 2020

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