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.

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

Client Intake Form





Name
Name

First Name


Last Name

Address
Address



City

State

Zip

Country

Put N/A if you do not have an email address





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. If you have had more than 5 addresses in the past 5 years, you can provided that additional information on-site.
Address
Address



City

State/Province

Zip/Postal

Country


Additional addresses

You may add up to 4 additional addresses. If you have had more than 5 addresses in the past 5 years, you can provided that additional information on-site.

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. If you have worked or gone to school at more than 5 places in the past 5 years, you can provided that additional information on-site.
Address
Address



City

State/Province

Zip/Postal

Country


Additional employers or schools

You may add up to 4 additional employers or schools . If you have worked or gone to school at more than 5 places in the past 5 years, you can provided that additional information on-site.

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. If you have more than 5 sons or daughters under 18 years old, you may provide that additional information on-site.
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?

Additional sons and daughters under 18 years old

You may list up to 4 additional sons or daughters. If you have more than 5 sons or daughters under 18 years old, you may provide that additional information on-site.

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. If you have been married more than 5 times, you may provide that additional information on-site.
Name of Spouse
Name of Spouse

First Name


Last Name




Spouse’s Immigration Status
If you’re currently married, does your spouse serve in the U.S. armed forces?

Additional spouses

You may list up to 4 additional spouses. If you have had more than 5 spouses, you may provide that additional information on-site.

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. If you have taken more than 5 trips outside of the U.S. in the last 5 years, you may provide that additional information on-site.




Additional trips outside of the U.S.

You may list up to 4 additional trips. If you have taken had more than 5 trips outside of the U.S. in the last 5 years, you may provide that additional information on-site.
Since you received your green card, have you ever had a single trip outside the USA that was 6 months (180 days) or longer?