Intake Form for Employee for (PERM) Labor CertificationTO BE COMPLETED BY EMPLOYEE: 1. Name * First Name Last Name a. If you have used other names than the one above, have changed your name at any time, or have included documents with other names, list those names here. Include any documentation pertaining to a change in your name: 2. Address Address 1 Address 2 City State/Province Zip/Postal Code Country 3. Phone * Country (###) ### #### 4. Email * 5. Date of Birth * MM DD YYYY 6. City and Country of Birth 7. Present Citizenship or Nationality: 8. Date of last entry (if in the United States) MM DD YYYY 9. Place of last entry: (if in the United States) 10. Present visa status: (if in the United States) Date of Expiration for Present Visa Status MM DD YYYY 11. Number on I-94 : (if in the United States) Date of Expiration for I-94 MM DD YYYY 12. Has another employer ever filed an I-140 on your behalf? Yes No 13. Has a family member ever filed an I-130 on your behalf? Yes No 14. Alien Registration Number A#: (if applicable) 15. Social Security Number: (if applicable) 16. Spouse and Children Provide name, date of birth and country of birth Spouse Child 1 Child 2 Child 3 Child 4 EDUCATION: list all colleges and universities that you attended, street address where school is located, the years you attended, and the degree received upon graduation (if you do not have a college degree, list your high school information): WORK EXPERIENCE: (start with present job and list all jobs including jobs abroad or prior to most recent degree) Company 1 Company 2 Company 3 Company 4 Thank you!
