US Client’s First Name:

US Client’s Last Name:

Is there (answer yes or no to the following statements. If yes, provide details):

1. Any temporary or permanent civil protection order or restraining order issued against the United States client.

Yes
No


2. Any Federal, State, or local arrest or conviction of the United States client for homicide, murder, manslaughter, assault, battery, domestic violence, rape, sexual assault, abusive sexual contact, sexual exploitation, incest, child abuse or neglect, torture, trafficking, peonage, holding hostage, involuntary servitude, slave trade, kidnapping, abduction, unlawful criminal restraint, false imprisonment, or stalking.

Yes
No


3. Any Federal, State, or local arrest or conviction of the United States client for-- (I) solely, principally, or incidentally engaging in prostitution; (II) a direct or indirect attempt to procure prostitutes or persons for the purpose of prostitution; or (III) receiving, in whole or in part, of the proceeds of prostitution.

Yes
No


4. Any Federal, State, or local arrest or conviction of the United States client for offenses related to controlled substances or alcohol.

Yes
No


5. Marital history of the United States client, including whether the client is currently married, whether the client has previously been married and how many times, how previous marriages of the client were terminated and the date of termination, and whether the client has previously sponsored an alien to whom the client was engaged or married.


1. Are you currently married?

Yes
No


2. Have you previously been married?

Yes
No

If Yes, please give the date and method of termination (divorce, annulment, death) of each marriage:



3. Have you ever sponsored an alien to whom you were either engaged or married?

Yes
No


6. The ages of any of the United States client’s children who are under the age of 18. Please write “No children” if you don’t have any.




7. All States and countries in which the United States client has resided since the client was 18 years of age.

I attest that the information above is correct. I acknowledge that a search will be made on the National Sex Offender Public Registry or on my state's offender registry. I give permission to Lovestory Agency to release all of this information to those foreign nationals from whom I request personal contact information.