JFCS Immigration Legal Services - Referral Form
Thank you for your interest in Legal Services for Immigrants and Internationals. Our office is open Monday through Friday from 9:00 am to 5:00 pm. If you or someone you know needs assistance with an immigration issue, please fill out this form.
Email address *
Legal Name *
What is your legal name?
Your answer
Gender *
How do you identify?
Address *
What is your current address? (Building Number, Apt Number, Street, City, State, Zip Code)
Your answer
Phone Number *
What is the best phone number(s) to contact you at?
Your answer
Email
What is the best email(s) to contact you at?
Your answer
Marital Status *
What is your marital status? (single, engaged, married, divorced, separated, widowed, etc)
Your answer
English Level *
What is your English language proficiency?
Country of Origin *
In which country were you born?
Your answer
Languages *
Which languages do you speak?
Your answer
Entry Visa Status *
How did you enter the United States? (Tourist, Student, Work, Family, Refugee, etc)
Your answer
Date of Entry *
On which date did you most recently enter the United States?
MM
/
DD
/
YYYY
Immigration Status *
What is your current immigration status?
Your answer
Birth Date *
What is your date of birth?
MM
/
DD
/
YYYY
A#
What is your Alien Registration Number? (You may find your A#/USCIS# on documents such as the I-94, Permanent Resident Card, Employment Authorization Document, and immigration court documents.)
Your answer
Criminal History *
Have you ever had any interaction with the police in the United States? If so, please explain date, charges and final outcome.
Your answer
Brief Statement of Problem *
What is your immigration issue?
Your answer
Referral From...
If you are referring this person for services, please tell us your name, number, and email.
Your answer
A copy of your responses will be emailed to the address you provided.
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