List your present and past membership in, or affiliation with every political

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                   List your present and past membership in, or affiliation with every political

                   organization, association, fund, foundation, guild, club, society or similar

                   group in the United States or in any other place since your 16th birthday.

              Please include any foreign military service.

Name and Location of

Organization

Beginning Date

of Membership

Ending Date of Membership

Name of Organization

VIOLATIONS: Please answer the following questions fully and truthfully. Do not include

                   traffic tickets or parking infractions. Attach a separate sheet of paper, if

                   necessary.

Have you ever been stopped, arrested, cited, charged, taken into custody or convicted in the United States, or in any foreign country? Yes         No

If Yes, please provide the following details:

1.

Please explain the circumstances surrounding your arrest:

Date of arrest: (mm/dd/yyyy):

Place of arrest: City: ; State: ; Country:

Charge:

Disposition (i.e. dismissed, convicted):

2.

Please explain the circumstances surrounding your arrest:

Date of arrest: (mm/dd/yyyy):

Place of arrest: City: ; State: ; Country:

Charge:

Disposition (i.e. dismissed, convicted):

3. 

Please explain the circumstances surrounding your arrest:

Date of arrest: (mm/dd/yyyy):

Place of arrest: City: ; State: ; Country:

Charge:

Disposition (i.e. dismissed, convicted):

I declare that the foregoing information is true and correct to the best of my knowledge and belief. I acknowledge and understand that failure to provide true and complete information and documentation may jeopardize my ability to obtain immigration benefits for my beneficiaries or myself and could result in serious repercussions.

I understand that communications to the responsible attorney or any member of the Choquette Law Group, P.S. (CLG) staff are confidential and that it is vitally important to my case that I discuss truthfully and cooperate fully with CLG in preparing my case. 

Further, I agree that I will advise CLG immediately upon any changes in the information provided above, including but not limited to, changes in address, telephone number or email address; arrests or convictions; marital status; and entries to the United States. 

_______________________        ________________________       _________________                        

Print Name                                     Signature                                        Date

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