Client Intake Form

To make an appointment at our upcoming clinic, complete the intake form and the Washington New Americans staff will get back to you to confirm your registration. Please fill this form out as completely as possible. For any items that do not apply to you, please type “N/A” into the field.

If your appointment is confirmed, WNA will print this form and have it available at our workshop for your appointment.

Client Intake Form (Revised)
Name
Name
First Name
Last Name
Address
Address
City
State
Zip
See date on “green card”
Including yourself and those who live separately if they appear on your taxes
How did you hear about this workshop?
Do you want to receive information about volunteer opportunities?

Please list all addresses where you have lived for the past 5 years

Please fill out the following sections as completely as you can. You will need to have all of this information prepared to fill out the U.S. citizenship application. Make sure to cover the entire 5-year period.
Address
Address
City
State/Province
Zip/Postal
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Please list everywhere you have worked or gone to school for the past 5 years

Please fill out the following sections as completely as you can. You will need to have all of this information prepared to fill out the U.S. citizenship application. Make sure to cover the entire 5-year period.
Address
Address
City
State/Province
Zip/Postal
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Provide the following information about all your sons and daughters under 18 years old

Include step-children, adopted children, and missing children. Please fill out the following sections as completely as you can. You will need to have all of this information prepared to fill out the U.S. citizenship application.
Full Name
Full Name
First Name
Last Name
Where do they live?
Relationship to you
Do you provide support for this child?
Is this child a lawful permanent resident?
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How many times have you been married?

Please fill out the following sections as completely as you can. You will need to have all of this information prepared to fill out the U.S. citizenship application. Make sure to cover the entire 5-year period.
Name of Spouse
Name of Spouse
First Name
Last Name
Spouse's Immigration Status
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If you're currently married, does your spouse serve in the U.S. armed forces?

List below ALL TRIPS of 24 hours or more outside of the U.S. in the last 5 years

Include trips to Mexico or Canada. Please fill out the following sections as completely as you can. You will need to have all of this information prepared to fill out the U.S. citizenship application. Make sure to cover the entire 5-year period.
Only list ONE country
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Since you received your green card, have you ever had a single trip outside the USA that was 6 months (180 days) or longer?