Appendix D Immigration Questionnaire for Physician Candidate

• Jurisdiction: United States

Please contact attorneys Greg Siskind (gsiskind@visalaw.com), Elissa Taub (etaub@visalaw.com), or Adam Cohen (acohen@visalaw.com) with any questions.

• What is your nationality? ______________________________________

• If you are a physician in residency or fellowship training in the U.S., please complete this section.

1. What type of visa do you have currently? ________________________________

2. What is the expected completion date for your training program? ________________________________

3. What is your area of specialization/training? ________________________________

4. If you are training on an H-1B visa, was the program exempt from the H-1B cap?_________

5. Have you ever applied for a J-1 waiver? If so, please provide the type of waiver, date of application and result:________________________________________________

6. Do you have a U.S. citizen or permanent resident spouse or adult children (over the age of 21)? _____________________________________________________

7. Has anyone ever filed a green-card petition on your behalf (including self-petitions)? _____. If so, please provide type of application, date of application, and result: _____________________________________________________

• If you are a physician who has completed training and are working in the U.S., please complete this section.

a. When did you complete your graduate medical training in the U.S.? _________________

b. What visa category did you use for training? __________

c. If you are in H-1B status currently, please list the date of your first H-1B approval:
_____________________________________________________

d. Have you ever been counted against the H-1B cap? ______________ When? _____________

e. Have you ever applied for a J-1 waiver? _______. If yes, please provide the type of waiver, date of application, and result: _____________________________________________________

f. If you are in the three years of service required for a J-1 waiver and are seeking to change employers during the three years, please provide a short explanation of the extenuating circumstances requiring your change of employer:

_____________________________________________________

_____________________________________________________

_____________________________________________________

g. Do you have a U.S. citizen or permanent resident spouse or adult children (over the age of 21)?

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