Part 3. For Initial Requests Only (continued)
4.Immigration Status on June 15, 2012 (e.g., No Lawful Status, Status Expired, Parole Expired)
5.a. Were you EVER issued an Arrival-Departure Record |
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(Form I-94, I-94W, or I-95)? |
Yes |
No |
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5.b. If you answered "Yes" to Item Number 5.a., provide your Form I-94, I-94W, or I-95 number (if available).
►
5.c. If you answered "Yes" to Item Number 5.a., provide the date your authorized stay expired, as shown on Form I-94, I-94W, or I-95 (if available).
(mm/dd/yyyy) ►
Education Information
6.Indicate how you meet the education guideline (e.g., Graduated from high school, Received a general educational development (GED) certificate or equivalent state-authorized exam, Currently in school)
7.Name, City, and State of School Currently Attending or Where Education Received
8.Date of Graduation (e.g., Receipt of a Certificate of Completion, GED certificate, other equivalent state- authorized exam) or, if currently in school, date of last attendance. (mm/dd/yyyy) ► 
Military Service Information
9.Were you a member of the U.S. Armed Forces or U.S.
If you answered "Yes" to Item Number 9., you must provide responses to Item Numbers 9.a. - 9.d.
9.a. Military Branch
9.b. Service Start Date (mm/dd/yyyy) ►
9.c. Discharge Date (mm/dd/yyyy) ►
9.d. Type of Discharge
Part 4. Criminal, National Security, and Public
Safety Information (For Initial and Renewal
Requests)
If any of the following questions apply to you, use Part 8. Additional Information to describe the circumstances and include a full explanation.
1.Have you EVER been arrested for, charged with, or convicted of a felony or misdemeanor, including incidents handled in juvenile court, in the United States? Do not include minor traffic violations unless they were alcohol-
If you answered “Yes,” you must include a certified court disposition, arrest record, charging document, sentencing record, etc., for each arrest, unless disclosure is prohibited under state law.
2.Have you EVER been arrested for, charged with, or convicted of a crime in any country other than the United
If you answered "Yes," you must include a certified court disposition, arrest record, charging document, sentencing record, etc., for each arrest.
3.Have you EVER engaged in, do you continue to engage in, or plan to engage in terrorist activities?

Yes
No
4.Are you NOW or have you EVER been a member of a
5.Have you EVER engaged in, ordered, incited, assisted, or otherwise participated in any of the following:
5.a. Acts involving torture, genocide, or human trafficking?
|
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Yes |
No |
5.b. |
Killing any person? |
Yes |
No |
5.c. |
Severely injuring any person? |
Yes |
No |
5.d. |
Any kind of sexual contact or relations with any person |
|
who was being forced or threatened? |
Yes |
No |
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6.Have you EVER recruited, enlisted, conscripted, or used any person to serve in or help an armed force or group
while such person was under age 15? |
Yes |
No |
7.Have you EVER used any person under age 15 to take part in hostilities, or to help or provide services to people