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DACA Renewal Intake Sheet
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* Indicates required question
Email
*
Your email
Have you ever filed a DACA application with our organization?
*
Yes
No
What is your complete name?
*
Your answer
What is your nationality
*
Your answer
What is your age?
Your answer
What is your gender?
Male
Female
Prefer not to say
Clear selection
What is your marital status?
*
Single, Never Married
Married
Divorced
Widowed
Other:
What is your phone number?
*
Your answer
When does your current DACA expire?
MM
/
DD
/
YYYY
What is your physical address? Please Include city state and zip code
Your answer
What is your mailing address (If you don't want your work permit mailed to your physical address)
Your answer
When did you enter the United States for the first time?
*
Your answer
Where did you enter the United States for the first time?
*
Your answer
Have you ever committed a moral crime or a crime involving drugs for which you have not been arrested?
*
Yes
No
If yes, please explain
Your answer
Have you ever been arrested, cited or detained or been in jail or prison?
*
Yes
No
If yes, please explain
Your answer
Have you ever been arrested by immigration at the border?
*
Yes
No
If yes, please explain
Your answer
Have you ever used a false document to gain entry to the United States?
*
Yes
No
If yes, please explain
Your answer
Have you ever been caught with false documents?
*
Yes
No
If yes, please explain
Your answer
Have you ever been fingerprinted crossing the border?
*
Yes
No
If yes, please explain
Your answer
Have you ever been deported?
*
Yes
No
If yes, please explain
Your answer
Have you ever received Unemployment Benefits in the United States?
*
Yes
No
If yes, please explain
Your answer
Have you ever applied and/or received public benefits for you and/or your children? Example: Food Stamps (SNAP), Welfare, Medicaid or Medicare, WIC, Public Housing, etc.
*
Yes
No
If yes, please explain
Your answer
Have you ever been involved with prostitution, drugs, or illegal gambling?
*
Yes
No
If yes, please explain
Your answer
Have you ever claimed to be a United States Citizen?
*
Yes
No
If yes, please explain
Your answer
Have you ever been involved with a terrorist group or espionage?
*
Yes
No
If yes, please explain
Your answer
Have you ever helped anyone enter the United States illegally?
*
Yes
No
If yes, please explain
Your answer
Have you ever used diplomatic immunity?
*
Yes
No
If yes, please explain
Your answer
Have you ever committed domestic violence?
*
Yes
No
If yes, please explain
Your answer
Have you ever been in front of a judge?
*
Yes
No
If yes, please explain
Your answer
Since the first time you entered the U.S. have you ever been arrested?
*
Yes
No
If yes, please explain
Your answer
Do you currently owe any traffic tickets?
*
Yes
No
If yes, please explain
Your answer
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