1. Name:

_________________________________________________
Last, First, Middle

2. Date of Birth:
__________/___________/__________
Day, Month, Year

3. Place of Birth (City, Province or other political subdivision and Country):

_________________________________________________________

4. Are Spouse & Child[ren] applying? Yes / No

Include(1) Full Name(Last,First,Middle) (2) Date of Birth (3)Place of Birth(city,province,country)

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

5. Current Place of Residence & Mailing Address:

______________________________________________________________
No. & Name of Street, Apartment No. ______________________________________________________________
City, State/Province, Country, Zip Code

6. Applicant's Native Country if Different from Country of Birth

____________________________________________________________

7.PHOTOGRAPH: (Attach a recent, preferably less than 6 months old, photograph of the applicant, 1.5 inches (37 mm) square in size, with the applicant's name printed on the back. The photograph (not a photocopy) should be attached to the entry with clear tape--do NOT use staples or paperclips, which can jam the mail processing equipment.)

8. SIGNATURE: ________________________________________________________

Use the following example when you mail your Envelope

This page was created on September 27, 1998