general questionnaire for consultations

8/7/2019 GENERAL QUESTIONNAIRE FOR CONSULTATIONS

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GENERAL QUESTIONNAIRE FOR CONSULTATIONS

Name Roa Adrian Dimalaluan

(Last) (First) (Middle) (Maiden)

Date of Birth__08/07/1979__ Nationality_Filipino____ citizen of Philippines(Month/Day/Year) (Country)

Other names used (including maiden name)_ _N/A____ Sex Male

Place of Birth Hinigaran, Negros Occidental, Philippines

(Town/Village) (State/Province) (Country)

U.S. Social Security No.__ N/A____Home Phone ___+63- 916-551-9899__

Alien No. _______N/A_________

E-mail address roa_ [email protected] Business Phone N/A

Present U.S. Address _______________N/A____________ Zip ______ N/A______

Permanent Address Abroad : Door 6, Santa Maria Dormitory, 18th Street, Lacson, Bacolod City, Philippines 6001

Phone Number Abroad : +63- 916-551-9899

Name of Father Roa Don Sr.

(Last) (First) (Middle)

Fathers Place of Birth Manila, Philippines

(City) (State) (Country)

Fathers Date of Birth ___ 04/14/1949___ Deceased? ____Yes________ Year December 10, 2003

Fathers Residence No. 04 Quezon Street, La Castellana, Negros Occidental, Philippines

Name of Mother Dimalaluan Avelina Guillen

(Last) (First) (Maiden)

Mothers Place of Birth Hinigaran, Negros Occidental, Philippines

(City) (State) (Country)

Mothers Date of Birth _01/24/1950__ Deceased? ____No_______ Year N/A

Mothers Residence No. 04 Quezon St., La Castellana, Negros Occidental, Philippines

Were any of your grandparents born in the U.S.? Yes __ No_X_

If so, where

Marital Status (M/W/D/SP/S)______Married_______ Date of Marriage___December 20, 2008_______


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Number of times married, including this marriage one (1)Spouses Name Cato Maybelle Espiritu


Place of Birth Bacolod City, Negros Occidental, Philippines

Spouses Date of Birth 05/27/1975 Citizenship U.S.

(Month/Day/Year)

Spouses U.S. Social Security No. 455-99-7182

Date/Place of Marriage December 20, 2008 / MUNICIPAL TRIAL COURT IN CITIES BR. III

Hall of Justice, Bacolod City, Philippines

Former Spouses Name ________ N/A__________________________


Former Spouses Date of Birth Place of Birth ____N/A_____ Citizenship N/A

(MM/DD/YY) (Country)

Date of Marriage _______N/A__________ Where _________N/A_________

Date of Termination of Marriage or Death ____N/A___________ Where? N/A

Residences last five years. (Present address first)

Street Address/Apt. #City/State/Zip Country From To

(Mo/Yr) (Mo/Yr)

-Door 6, Santa Maria Dormitory, !8th Street, Lacson, Bacolod City, Negros Occidental, Philippines

October 2007 to present

-Door 1, Huellar Building, Villamonte, Bacolod City, Negros Occidental, Philippines

November 2006 to October 2007

- 929 Madia-as Street, Villamonte, Bacolod City, Negros Occidental, Philippines

March 2006 to November 2006

-Lizares

Frm __ To__

-No. 04 Quezon Street, La Castellena, Negros Occidental, Philippines

Frm ____ To ___

Last address outside of U.S. of more than one year. From (Mo./Yr) To (Mo/Yr)

Door 6, Santa Maria Dormitory, 18th Street, Lacson, Bacolod City, Negros Occidental, Philippines

From October 2007 to Present

Employment last five years. (Present employment first)


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Name/Address/Occupation/Supervisor/Tel. No. Salary From To

(Mo/Yr) (Mo/Yr)Riverside Medical Center,Incorporated/ Php8,577.84/mo. 11/2004 - Present

North Drive/ Bacood City/ Philippines/

Nurse/ Mrs. Oliva V. Alabado

Last Employment Abroad : N/A

Name/Address/Occupation/Supervisor/Tel. No. Salary From To

(Mo/Yr) (Mo/Yr)

__________________________N/A_____________________________

Current Employers Tax Identification Number __N/A___

Current Employers Gross Income __N/A__ Net Income ___N/A___ Date Established __N/A___

Employees ___N/A___ Supervisor (Name/Title/Tel. No.) ___N/A___ Director For Nurses___N/A_____

Education: High School?_La Castellana National High School____ College? __Riverside College ____

Degrees Earned Bachelor Of Science In Nursing

Date/Place of last arrival in U.S. ____________N/A_______ _________

(Month/Day/Year) (Place)

Has a prior visa petition ever been filed? __No____If YES, then answer the following:

Where When Approved? N/A

Means of travel into U.S. ____________N/A__________ Inspected? _____N/A___

Status at entry (visitor, student) __N/A___

Passport No. Passport Issue Date ___N/A___

Passport Expiration Date___ N/A___

Consulate Visa Issued __________N/A______Visa Number___ N/A___Date Visa Issued ________N/A_______ Visa Expiration Date ______N/A_______ OR

Indefinite (yes/no)______N/A_____

Visa Classification ___N/A___

I-94 No. __________N/A________ I-94 Issue Date

I-94 Expiration Date Duration of Stay ____N/A____

Name Exactly as it Appears on I-94 ___N/A___


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List children, including stepchildren (use attachment if necessary):

(1) Name : Amielle Marc Cato Roa

Relationship : Son

DOB : March 11, 2009

City, State of Birth : Bacolod City, Negros Occidental

Country of Birth : Philippines

Address (if different) 12807 Newberry Street, Sugar Land, Texas 7748

U.S. Soc. Sec. No.: 627-29-1004

(2) Name : Isabelle Carolyn Cato

Relationship : Stepdaughter

DOB: September 5,1996

City, State of Birth : Houston, Texas,

Country of Birth : United States of America


U.S. Soc. Sec. No.: 633-54-3250

(3) Name : Adriana Belle Cato

Relationship : Stepdaughter

DOB: September 18, 2003

City, State of Birth : Sugar Land, Texas

Country of Birth : United States of America


U.S. Soc. Sec. No.: 636-88-2488

List ALL present/past membership in groups of any kind:

Group Name Location (City/State) From To

(Mo/Yr) (Mo/Yr)

___________________________N/A________________________________________________________

___________________________N/A____________________________________________________________


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Have you ever filed for Permanent Residence in the U.S.? Yes ___No__X__

If yes, give date and place of filing: N/A

Have you ever committed a crime? __No__ been arrested? _No_ been granted pardon? No

(include all traffic tickets)

If answered YES to any of the above, give the following information:

Date Place (City/State/Country) Nature of Offense Outcome N/A

Have you ever been given public assistance? No

If YES, explain:

N/A

Have you ever:

Committed a crime of moral turpitude or drug-related offense for which

you were not arrested? (Y/N) N

Been arrested, cited, charged, indicted, fined or imprisoned for breaking

a law, excluding traffic violations? (Y/N) N

Been the recipient of an act of clemency or similar action? (Y/N) N

Exercised diplomatic immunity to avoid prosecution in U.S.? (Y/N) N

Received public assistance in U.S. from any source, or likely to in the future? (Y/N) N

Engaged in prostitution in past 10 years, or likely to in future? (Y/N) N

Engaged in unlawful commercialized vice such as illegal gambling? (Y/N) N

Encouraged any alien to enter U.S. illegally? (Y/N) N

Trafficked in any controlled substance? (Y/N) N

Been in any way involved in any terrorist activity? (Y/N) N

Engaged in espionage or intend to once in the U.S.? (Y/N) N

Been a member of or affiliated with the Communist Party? (Y/N) N

Engaged in genocide or persecuted any person because of race, religion,


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national origin or political opinion? (Y/N) N

Been deported or excluded from the U.S.? (Y/N) N

Committed fraud in order to obtain entry into the U.S.? (Y/N) N

Left the U.S. to avoid being drafted into the U.S. Army? (Y/N) N

Been a J nonimmigrant visitor and not complied with the 2-year foreign

residence requirement or obtained a waiver? (Y/N) N

Withheld custody of a U.S. citizen child from a person granted custody of

the child? (Y/N) N

Been a polygamist or plan to practice polygamy in the U.S.? (Y/N) N

Claimed to be a U.S. citizen? (Y/N) N

If answered YES to any of the above, explain fully below:

N/A

Date __________________ Adrian D. RoaSignature

general questionnaire for consultations

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