Fill and Sign the Fire Service Application Form PDF

OMB No: 1615-0070; Expires 01/31/2015 I-643, Health and Human Services Statistical Data for Refugee/Asylee Adjusting Status Department of Homeland Security U.S. Citizenship and Immigration Services Print or type in blue or black ink. Last (Family) First (Given) 1. Name: Country of Birth: Middle Today's Date: (mm/dd/yyyy) Country of Citizenship/Nationality: Native Language: Date of Birth (mm/dd/yyyy) Telephone Number (with area code) Alien Registration Number: ASocial Security Number: Cellphone Number (with area code) Current Address: (Number, Street, and Apartment No.) (State) (City) 2. My three most recent cities of residence in the United States have been: City or Town 3. There are Name (List most recent first) State From (mm/dd/yyyy) of whom are employed. members of the household, Relationship Gender Date of Birth Country of Alien Number (mm/dd/yyyy) to Me M/F Birth (Self) (Zip Code) To (mm/dd/yyyy) Present (Please use another sheet(s) if needed) Currently Employed? Attending School? Yes No Yes No (Self) 4. My employment since entering the United States has been: (List most recent first) Location To From Company Name City, State (mm/dd/yyyy) (mm/dd/yyyy) Check One Wage Per Part Full Hour Time Time Job Title My major occupation or profession before coming to the United States was: 5. My education before coming to the United States was: Grades 1-8 Some high school High school diploma Technical school Technical school certificate Some university University diploma Graduate studies Professional training Graduate degree 6. I have had the following training or education in the U.S. Type of Training/Education (Check all that apply) My knowledge of English was acquired by: (Check all that apply) Use in another country Training in the U.S. Use in the U.S. Training in refugee camp Training in another country Other (Please explain): (Check all that apply) High School College Technical/Vocational Check If Completed 7. English Language Skills: (Check one) Speaking None Good A Few Words Fair Reading Course of Study Check If Still Attending None Good None A Few Words Fair A Few Words Fair Writing Other (specify): Good 8. Since in the United States, list as many types of public assistance (excluding emergency medical treatment) that you have received or someone has received on your behalf. Please include public assistance received from the U.S. Government or any State, county, city, or municipality. Public Assistance From (mm/yyyy) To (mm/yyyy) Public Assistance Cash assistance (Welfare) To (mm/yyyy) Medical assistance Food Stamps From (mm/yyyy) Other (specify): SSI Form I-643 (01/08/13) Y Page 1