Date of Birth:
Date of Birth(Spouse):
Country of Birth:
Country of Birth(Spouse):
Marital Status: ---MarriedSingleDivorcedSeparatedSame Sex Relationship
If Divorced, what is the date that the divorced was finalized?
Please list all children (if any):Name, Sex, Date of Birth, Living with you?, Immigrating with you?
If you have any dependent children not immigrating with you, please explain:
What is your purpose in coming to the U.S.? (i.e. Education, Employment, Reuniting with Family, etc.)
Do you or spouse currently have any relatives who are a citizen or permanent resident living in the U.S.? yesno
If yes, please explain their relationship (ie Aunt, Uncle etc.) and their status in the U.S. (i.e. Citizen, Permanent Resident):
What is your highest level of Education? (Select completed degree only): No EducationHigh SchoolUndergraduate Degree (or equivalent)Graduate Degree (Masters or equivalent)Graduate Degree (PhD or equivalent)DoctorateOther
If you or your spouse/partner graduated from a four year institution or higher, please list any majors or degrees that you or your spouse/partner has obtained :
How many years of full time professional experience do you have?
Your Current Occupation:
What is your level of the English Language? NativeFluentIntermediateBasicNone
Are you or your spouse interested in one-on-one English tutoring? YesNo
Are you or your spouse interested in group lessons for learning English? YesNo
Do you or your spouse need help in preparing for TOEFL? YesNo
Please list anyone else besides you or your spouse who may be interested in the above services:
Do you need help in planning and making arrangements for you and your family for travel to and from the U.S.? YesNo
Do you require any international shipments of personal items to the U.S. from your country of origin? YesNo
Do you have any pets that need relocating? YesNo
Do you need assistance with IRS registration? YesNo
Do you need assistance with filing taxes? YesNo
Do you need assistance with Apartment/Housing search? Lease negotiations? YesNo
Do you need assistance with purchasing a home? YesNo
Do you require assistance with finding a career here in the U.S.? YesNo
Do you have any children that require attendance at a child care center? Pre-school? K-12? YesNo
Do you require assistance with Health Care Insurance? YesNo
Do you require assistance with finding doctors or health care facilities? YesNo
Are you interested in athletic opportunities for leisure for your family? YesNo
Do you require assistance for immigration related matters? (i.e. interviews, paperwork, translation of immigration documents) YesNo
Do you need assistance with the driver’s license application process? YesNo
Do you require a personal driver? YesNo
Have you or your spouse managed/owned a business? If yes, Please provide a description of your business experience (past and present), occupation title, responsibilities at the job and the number of years of experience:
Are you interested in starting your own company here in the U.S.? YesNo
Please include any additional information that you would like us to know:
I, the undersigned, hereby certify that the information on this form is true and correct and can provide proof upon request. I further declare that I fully understand the contents of this form and previously mentioned conditions. I waive Destination USA Consulting and its subsidiaries of all present and future liability on evaluations provided by them. I understand that the assessment will be provided based on the information I have provided in this form.
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