Please answer all questions that apply to you.

 Part I – Contact Information

First Name	Middle Name	Last Name

Current Job

Company Name	Job Title

Preferred address for receiving mail:  office      home      other

	Home	Office	Other:
Telephone
Fax
Email
Address   Line 1
Address   Line 2
Address   Line 3

Part II – Qualifications (Required Fields)

I have received the following award(s) or honor(s) from an employer association, university, etc.:

Title of award or   honor	Name of   organization giving award/honor	Significance of   award (including approx. # or % of others receiving award per year)

I am a member of professional association(s) that requires specific achievements or credentials to qualify for membership:

Name of Association	Criteria for Membership	Years of Membership

I have been quoted or my name has been mentioned in the following press (newspapers, magazines, industry publications, academic journals, televisions, etc.):

Name of Publication   or Other Media	Subject of the   Media Coverage

I have not been quoted or mentioned by name in the press, but I have been involved in projects or endeavors that have received media coverage.  I can get copies of the article(s), and an authority in my field will attest to the significance of my work relative to the media coverage.  Examples of this press coverage are as follows:

Name of Publication   or Other Media	Subject of the   Media Coverage

I have been asked to evaluate or judge (by myself or on a panel or team) the work of others in my field (e.g., an editorial review board, grant-giving advisory committee, professional association conference planning position, etc.):

Organization Inviting Me To Judge	Description of the Event,   Publication, Etc.

My compensation is high in comparison to others in my field (include stock options and other forms of compensation).  Last year’s total gross compensation was (USD):

Last Year’s total   gross compensation was (give base salary first, then other compensation):

The following experts in the field (e.g., vice presidents or other officers, professors, etc.) at prestigious companies, universities, government agencies (U.S. or foreign) or other entities would probably be willing to sign supporting letters on my behalf.  (Name at least three people – NO MORE THAN ONE PERSON PER ENTITY).  Name at least one person from a company where you have never worked or a university where you have not matriculated.

Name of Company, University, or Other   Entity	Job Title of Reference

I have been contacted by a “headhunter” or recruiter in recent years and I would be able to call this person to see if s/he can help establish my stature in the field.

My work is known to an official of a United States government agency and I believe a qualified employee of that agency would sign a letter on my behalf confirming that my current or proposed work is in the nation’s interest.

Name of U.S. Government Agency:

United States interests served or improved (check all that apply):

U.S. Economy                      Affordable Housing

Job Creation                         Wages or working conditions for U.S. workers

Health Care                           Education for U.S. children or under-qualified workers

Environment                          Other:

Part III – Qualifications

(Optional Fields – May Include CV or Resume in lieu of Completing)

Please fill out the following fields only if you are not providing your resume/c.v. – OR – if your resume/c.v. does not fully reflect the information requested in Part III.

I have made significant original contributions in my field of endeavor.  Briefly describe the contributions or achievements below and mention any patents, copyrights, etc.  This is a mandatory qualification, so take time to describe it here if it’s not reflected on your provided resume or C.V.:

Description

I have published article(s), book(s), and/or paper(s) on topics related to my field:

Title	Publication/Publisher	Description	Date Published

I have played a leading or critical role for an organization, academic entity, public agency, committee, or distinguished company within my field:

Name of   Organization or Company	Role or Title

If applicable – I have presented or exhibited my work in artistic exhibitions or showcases:

Event	Description of Work Presented or   Displayed

If applicable – my work has met with commercial success in the performing arts, as shown by box office receipts, or record/cassette/CD/video sales:

Description	Quantification of   Success

I have a diploma from the following universities (again, only fill this out if you’re not attaching a resume or c.v.):

Name of University	City & Country	Type of Diploma

Job history.  Last three positions (only fill out if you’re not attaching your resume or c.v.):

Job Title	Name of Company	City, State, &	Dates of Employment:
		Country	from                    to

There is other evidence not listed above which may help demonstrate my stature:

Description

Part IV – Current U.S. Status and History

Nationality	Current U.S. Immigration Status	Expiration Date of Visa

If you are currently in H-1B or L-1 status, how much time do you have left before having to get a green card or leave the U.S. for one year (e.g., H-1B maximum is 6 years)?  Count only the times you have actually worked in H-1B or L-1 status, not your visa approval dates.   Time Left: Months/Years

Have you ever been on a J-1 visa   Yes     No

If you answered Yes above, will a waiver of the 2-year foreign residency requirement be needed?    Yes      No.            Explain:

Will you be seeking U.S. permanent residence for a spouse and/or children?  If yes, please fill in their information.

	Name	Nationality	Date of birth	Current Status
Spouse
Child
Child
Child

** This newsletter/memo is provided for informational and discussion purposes only. It does not act as a substitute for direct legal contact on an individual basis **