Staple Passport

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H2B Registration Form
Personal Information

Name: ………………………………………….. …………………………………………………. …………………………………………………

First Middle Surname

Address: ……………………………………………………………………………………………………………..………………………………………………

Email: …………………………………………………………………….. Telephone: (Home)………………………………. (Cell) …………………………………

Date of Birth: ……..….……………………. Place of Birth: …………………………….………… Passport#: ……………………………….

Passport Expiry Date: ……./……./……. Passport Issue Date: ……/……./……TRN#: …………………………………………

Gender: Male Female Marital Status: Married Single Divorced

How did you hear about MaxJ? Family Member Advertisement Friend

Give name and contact number of the person ……………………………………………………….

Have you ever been convicted of a crime? Yes No

Have you ever been Issue/Refused a VISA? Yes No , Give date ………………………

Has anyone ever filed an Immigrant VISA petition on your behalf? Yes No

Education Information

Name of Last School Attended: ………………………………………………………………………………………………………………………………

Address: ……...………………………………………………………………………………………… Telephone: ……………….…………………………………………

Course of Study: ………………………………… Level Obtain, If any: Certificate Diploma Degree Other ………………………….

Travel Experience

Have you ever been to the USA? Yes No If yes, give date: ……..…./...………/…………..
What type of visa? ………………………………………………………………

Emergency Contact

Name: ……………………………………………………………………………………….. Relation: ………………………………..

Address: ………………………………………………………………………………………………………… Tele: (C) ………………………….… (W) ……………………………….

Work Experience

List most recent work experience:

Company Name: ……………………………………………………………………………………… Position: …………………………………………. Tele: ………………………………..
Supervisor Name: …………………………………………. Location: (City, Country) ...............................................................................................
Duration: From (MM/YY) ……............ /................... To (MM/YY) ................. /.................... # of Months: …………………
Last Two Employers

Not including current employer:

Company Name: ……………………………………………………………………………………… Position: …………………………………………. Tele: ………………………………..
Supervisor Name: …………………………………………. Location: (City, Country) ...............................................................................................
Duration: From (MM/YY) ……............ /................... To (MM/YY) ................. /.................... # of Months: …………………

Company Name: ……………………………………………………………………………………… Position: …………………………………………. Tele: ………………………………..

Supervisor Name: …………………………………………. Location: (City, Country) ...............................................................................................
Duration: From (MM/YY) ……............ /................... To (MM/YY) ................. /.................... # of Months: …………………

I certify that all the information submitted on this application is true and complete and by signing this
document, I acknowledge that I have thoroughly read, understand and agree with the terms and conditions
of this contract.

Signature: ………………………………………………………………. Date: ………/………/……….