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Ukraine Dating Agency

Example of U.S. CLIENT QUESTIONNAIRE

U.S. CLIENT QUESTIONNAIRE

Please indicate whether any of the following applies to you:

Yes □ No □ Any temporary or permanent civil protection order or restraining order issued against you at any time.

If you replied “Yes”, please provide, for each order:

Type of Order* Date Issued Relationship to Person Issued Order

1. ________________ __________ ______________________________

2. ________________ __________ ______________________________

3. ________________ __________ ______________________________

4. ________________ __________ ______________________________

 

* For example, “protection order”, “no contact order”, “restraining order”, “anti-harassment order”

 Yes □ No □  Any Federal, State, or local arrest or conviction of you for homicide, murder, man­slaughter, assault, battery, domestic violence, rape, sexual assault, abusive sexual contact, sexual exploi­tation, incest, child abuse or neglect, torture, traf­ficking, peonage, holding hostage, involuntary ser­vitude, slave trade, kidnapping, abduction, unlawful criminal restraint, false imprisonment, or stalking.

If you replied “Yes”, please provide the following information:

ARRESTS -

Arrest Charge Date of Arrest Disposition County/State

1. _____________ ____________ ______________ ________________

2. _____________ ____________ ______________ ________________

3. _____________ ____________ ______________ ________________

4. _____________ ____________ ______________ ________________

CONVICTIONS -

Offense Conviction Date Sentence County/State

1. _____________ ____________ ______________ ________________

2. _____________ ____________ ______________ ________________

3. _____________ ____________ ______________ ________________

4. _____________ ____________ ______________ ________________

 Yes □ No □ Any Federal, State, or local arrest or conviction of you for solely, principally, or incidentally engaging in prostitution; a direct or indirect attempt to procure prostitutes or persons for the purpose of prostitu­tion; or receiving, in whole or in part, of the proceeds of prostitution.

If you replied “Yes”, please provide the following information:

ARRESTS -

Arrest Charge Date of Arrest Disposition County/State

1. ___________________ ____________ ______________ ________________

2. ___________________ ____________ ______________ ________________

3. ___________________ ____________ ______________ ________________

4. ___________________ ____________ ______________ ________________

CONVICTIONS -

Offense Conviction Date Sentence County/State

1. ___________________ ____________ ______________ ________________

2. ___________________ ____________ ______________ ________________

3. ___________________ ____________ ______________ ________________

4. ___________________ ____________ ______________ ________________

 

Yes □ No □ Any Federal, State, or local arrest or conviction of you for offenses related to con­trolled substances or alcohol.

If you replied “Yes”, please provide the following information:

ARRESTS -

Arrest Charge Date of Arrest Disposition County/State

1. ___________________ ____________ ______________ ________________

2. ___________________ ____________ ______________ ________________

3. ___________________ ____________ ______________ ________________

4. ___________________ ____________ ______________ ________________

CONVICTIONS -

Offense Conviction Date Sentence County/State

1. ___________________ ____________ ______________ ________________

2. ___________________ ____________ ______________ ________________

3. ___________________ ____________ ______________ ________________

4. ___________________ ____________ ______________ ________________

 Yes □ No □ Are you currently married?

If you replied “Yes”, please explain:

_______________________________________________________

_______________________________________________________


Yes □ No □ Have you previously been married?

If you replied “Yes”, please provide the following information for ALL previous marriages:

Divorce/Annulment/Death* Date Grounds for Divorce/Annulment

1. ____________________ _______ _______________________________

2. ____________________ _______ _______________________________

3. ____________________ _______ _______________________________

4. ____________________ _______ _______________________________

5. ____________________ _______ _______________________________

6. ____________________ _______ _______________________________

7. ____________________ _______ _______________________________

 Yes □ No □ Have you previously sponsored a foreign-born spouse or fiancé(e)?

If you replied “Yes”, please provide, for each sponsorship:

 Visa type* Petition Approved? Visa Issued? Year & Place of Issuance

1. _____________ _______________ ___________ ____________________

2. _____________ _______________ ___________ ____________________

3. _____________ _______________ ___________ ____________________

4. _____________ _______________ ___________ ____________________

 

* For example, “K-1”, “I-130”, “CR-1”

 

 Yes □ No □ Children who are under the age of 18.

If you replied “Yes”, please list their ages:

____________________________


Please list ALL the Counties and States of your residence since you were 18 years old:

County State Year(s)*

1. ____________________ ____________ ________________

2. ____________________ ____________ ________________

3. ____________________ ____________ ________________

4. ____________________ ____________ ________________

5. ____________________ ____________ ________________

6. ____________________ ____________ ________________

7. ____________________ ____________ ________________

8. ____________________ ____________ ________________

9. ____________________ ____________ ________________

10. ___________________ ____________ ________________

 

* For example, “1994 to 1998”

 

Please use the space below for any information that could not fit in the spaces above for ANY of the questions in this form:

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

 

If you would like us to forward some of your comments to the ladies with this form information, please provide below:

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

I certify that the above information is complete and accurate. I agree to notify (none) immediately if there are any changes in the information above or if any new information should arise in the future that would be needed to keep this disclosure completely accurate and up-to-date.

I hereby give permission to (none) to release the information in this form to all foreign national clients of (none) whom I request to be the recipients of said information, whether I make such request with this attestation or in the future.

I hereby agree to RELEASE, INDEMNIFY, AND HOLD HARMLESS (none), its officers, agents, servants, or employees, from and against any claims, demands, actions, liens, rights, subrogated or contribution interests, debts, liabilities, judgments, costs, and attorney’s fees, arising out of, claimed on account of, or in any manner predicated upon (none) release of my information herein disclosed to foreign national clients of (none).

_________________

Please print name

________________ _______________

Signature date

 

Click Here for an example of Questionnaire to be completed by a Female client!