National Institutes of Health

**Division of International Services**

FDA LAWFUL PERMANENT RESIDENT (LPR) PETITION WORKSHEET

[To be completed by the Beneficiary]{.underline}

**This form will [not]{.underline} be accepted unless the FDA has
submitted an approved request to DIS.**

**INSTRUCTIONS: In order to help DIS process your LPR petition, please
complete this form and return it to your DIS Immigration Specialist with
all required supporting documents. *Type or print clearly. All questions
MUST be answered. If not applicable, write \"N/A.\"* Please see
checklist for additional documents required for this petition.**

A.  Personal

  ------------------- ------- ------- ------- ------- ------- ------- --------- ---------- ------- ----------- ------- -------------------------- ---------------- ------- ------- ------------ ------- ------- --------- --------- -------- ------- ------- --------- ------- -------
  Last Name:                                                                                                   First                                                                                                                Full                                       
                                                                                                               Name:                                                                                                                Middle                                     
                                                                                                                                                                                                                                    Name:                                      

  All Other Names                                                                                                                                                                                                                                                              
  Used:                                                                                                                                                                                                                                                                        

  Date of Birth:                                                      e-mail:                                                                                                                                   Gender:                                                        
                                                                                                                                                                                                                Male                                                           
                                                                                                                                                                                                                Female                                                         

                              mm / dd                                                                                                                                                                                                                                          
                              / yy                                                                                                                                                                                                                                             

  Soc. Sec. No. (if                                                                                Marital                                                                                                                                                                     
  available):                                                                                      Status:                                                                                                                                                                     
                                                                                                   Married                                                                                                                                                                     
                                                                                                   Single                                                                                                                                                                      
                                                                                                   Children:                                                                                                                                                                   
                                                                                                   Yes No                                                                                                                                                                      

  Country of Birth:                                                                                                    Country of                                                                                                                                              
                                                                                                                       Nationality/Citizenship:                                                                                                                                

  City/Town/Village                                                                                                                               Province/State                                                                                                               
  of Birth:                                                                                                                                       of Birth                                                                                                                     

  Home Country                                                                                                                                                                                                                                                                 
  Address:                                                                                                                                                                                                                                                                     

  Work Site/Lab                                                                                                                                                                                                                                                                
  Address:                                                                                                                                                                                                                                                                     

  Daytime Phone \#                                                                                                                                                         Work                                                                                                
  *(with area/country                                                                                                                                                      Phone                                                                                               
  code*):                                                                                                                                                                  \# in                                                                                               
                                                                                                                                                                           US:                                                                                                 

  US Home Address (if                                                                                                                                                                                                                                                          
  available):                                                                                                                                                                                                                                                                  

  E-Mail Address (*if                                                                                                                             Current Salary                                                          \$                                                   
  any*)                                                                                                                                           (per year):                                                                                                                  

  Passport Country of                                                           Passport                                                                                           Expiration                                                                Date              
  Issuance:                                                                     #:                                                                                                 Date:                                                                     Issued:           

                                                                                                                                                                                                mm / dd                                                                        mm / dd
                                                                                                                                                                                                / yy                                                                           / yy
  ------------------- ------- ------- ------- ------- ------- ------- --------- ---------- ------- ----------- ------- -------------------------- ---------------- ------- ------- ------------ ------- ------- --------- --------- -------- ------- ------- --------- ------- -------

***B. Immigration Status* (complete only if currently inside the US; if
not currently in the US, check here** **)**

<table>
<colgroup>
<col style="width: 15%" />
<col style="width: 10%" />
<col style="width: 6%" />
<col style="width: 20%" />
<col style="width: 1%" />
<col style="width: 14%" />
<col style="width: 4%" />
<col style="width: 2%" />
<col style="width: 7%" />
<col style="width: 3%" />
<col style="width: 12%" />
</colgroup>
<tbody>
<tr class="odd">
<td>Initial Arrival Date:</td>
<td colspan="2">     </td>
<td>Most Recent Arrival Date:</td>
<td colspan="2">     </td>
<td colspan="2">1-94 #:</td>
<td colspan="3">     </td>
</tr>
<tr class="even">
<td></td>
<td colspan="2">mm / dd / yy</td>
<td></td>
<td colspan="2">mm / dd / yy</td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td colspan="10">Current Non-immigrant Status: F-1 F-2 J-1 J-2 H-1B H-4
TN Other (specify);</td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="5">Expiration Date (ending date on I-20, EAD, IAP-66,
I-797, I-94, etc.)</td>
<td colspan="2">     </td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td colspan="5"></td>
<td colspan="2">mm / dd / yy</td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td colspan="11"><p>Were you ever in J-1 Exchange Visitor Status? Yes
No</p>
<p>If yes, provide evidence that the home residence requirement was
fulfilled or was not applicable.</p></td>
</tr>
<tr class="odd">
<td colspan="11">Do you have any plans to travel outside of the US
between now and the <strong>filing</strong> date of this petition? Yes
No</td>
</tr>
<tr class="even">
<td colspan="11">In addition, do you have any plans to travel outside of
the US while this petition is <strong>pending</strong> with USCIS? Yes
No</td>
</tr>
<tr class="odd">
<td colspan="2">If yes, please list dates of travel:</td>
<td colspan="7">     </td>
<td colspan="2"></td>
</tr>
</tbody>
</table>

**Consult with your Immigration Specialist before finalizing travel
plans!!**

\*USCIS (U.S. Citizenship and Immigration Services) is an agency of the
Department of Homeland Security.

#### 

LAWFUL PERMANENT RESIDENT (LPR) PETITION WORKSHEET

[To be completed by the Beneficiary]{.underline}

#### **C. Visa Application Information** (required)

Do you plan to apply for your immigrant visa abroad (Consular process)?
Yes No If yes, please indicate:

  ------- ------------------------ ----------- ------------------------------
  City:                            Foreign          
                                   Country:    

  ------- ------------------------ ----------- ------------------------------

If you are in the US and plan to apply for adjustment of status to that
of a lawful permanent resident:

  --------------------------- -------------------------------------------
  Last permanent residence         
  address abroad:             

  --------------------------- -------------------------------------------

If your native alphabet is other than Roman letters, on a
**[separate]{.underline}** sheet of paper, write your name and home
country address in your native alphabet. Write your name (in Roman
letters) at the top of the sheet of paper.

###### 

###### D. Petition Information

Are you in removal proceedings? Yes No

Has an immigrant visa petition ever been filed by you or on your behalf?
Yes No

If you answered yes to any of the above questions, on a separate sheet
of paper, please provide the case number, office where filed, and final
decision on petition.

***E. Family Information. Provide the name of your spouse and all
children.***

  ----------------------- -------------- ----------------------- --------------
  Name                    Relationship   Date of Birth           Country of
  *(First/Middle/Last)*                  *(mm/dd/yyyy)*          Birth

                                                                 

                                                                 

                                                                 

                                                                 
  ----------------------- -------------- ----------------------- --------------

*F. Signature*

  ------------------- ------------------------- -- -------------------------- -- ---------- --
  I certify that I                                                                          
  have read all                                                                             
  information                                                                               
  provided on this                                                                          
  worksheet. The                                                                            
  information above                                                                         
  and documents                                                                             
  submitted as they                                                                         
  relate to the                                                                             
  instant petition                                                                          
  are true and                                                                              
  correct. I                                                                                
  understand that any                                                                       
  misrepresentation                                                                         
  of information or                                                                         
  document fraud may                                                                        
  result in                                                                                 
  termination of my                                                                         
  employment at FDA.                                                                        
  I also understand                                                                         
  that information                                                                          
  and materials                                                                             
  submitted with this                                                                       
  worksheet may be                                                                          
  shared with other                                                                         
  government                                                                                
  agencies. In                                                                              
  addition, I                                                                               
  understand that my                                                                        
  application could                                                                         
  be delayed as a                                                                           
  result of mandatory                                                                       
  Department of                                                                             
  Homeland Security                                                                         
  (DHS) security                                                                            
  checks. To the best                                                                       
  of my knowledge,                                                                          
  there is no adverse                                                                       
  information that                                                                          
  would negatively                                                                          
  affect the LPR                                                                            
  petition. I                                                                               
  understand that DHS                                                                       
  determines final                                                                          
  approval of the LPR                                                                       
  petition.                                                                                 

                                                                                            

                      Signature of Beneficiary     Print Name of Beneficiary     mm / dd /  
                                                                                 yy         
  ------------------- ------------------------- -- -------------------------- -- ---------- --

**FDA LPR CHECKLIST**

**Submit the following required documents**

**Any document not in English must be translated**

***A. All applicants (Form I-140):***

 1. Copy of ALL diplomas/certificates AND English translation if
applicable (minimum of MD or PhD required)

2. Copy of transcript if your field of study is not indicated on
diploma/certificate

> 3. Credentials evaluation if degree earned abroad (highly recommended,
> but not required; for a list of evaluators, go to
>
> <http://www.naces.org/members.htm>)

4. Current Curriculum Vitae (CV)

5. Copy of Form SF-50 (indicating the position that qualifies for
LPR-sponsorship, e.g. Staff Scientist)

6. If your native alphabet is other than Roman letters, write your name
and home country address in the native alphabet

on a separate sheet of paper. Write your name (in Roman letters) at the
top of the sheet of paper.

7. Copy of passport biographical page (including passport expiration
date)

8. Unaltered Original Document and Translation form (page 5)

9. Evidence to demonstrate I-140 qualifications as outlined by your
Immigration Specialist.

*Please separate evidence by category and submit unbound (use clips,
instead of staples, to group items together).*

B. Petition Fee: check or money order in US dollars, drawn on a US bank,
made payable to the "Department of Homeland Security":

10. Fee \$475 (payable by beneficiary): **[\*\*DO NOT SUBMIT CHECK UNTIL
NOTIFIED BY THE DIS\*\*]{.mark}**

**IN ADDITION, if you are eligible and plan to file a Form I-485,
Adjustment of Status Application, complete the following:**

***(NOTE: If you have ever violated your immigration status in the US or
have other reasons to believe you may have problems in obtaining Lawful
Permanent Residence, please consult an immigration attorney.)***

***C. Primary applicant:***

11. I-485 Adjustment of Status Application, fully completed, signed,
w/fee (\$930) and:

Two photos (lightly write your name in pencil on the reverse)

Copy of I-140 Approval Notice or Receipt Notice (if not concurrently
filed)

Biometric Fee (\$80)

I-693, Medical Exam (**must** be completed by a USCIS-designated
physician)

G-325A, Biographical Information

Copy of birth certificate

Copy of passport biographical page (including passport expiration date)

Copy of all nonimmigrant visa stamps from passport

Copy of Form I-94

Copy of I-797 Approval Notice(s) for current immigration status

Letter confirming employment

Immigration History w/supporting evidence (optional)

Marriage Certificate (if applicable)

Criminal History (if applicable; refer to page 3 of the USCIS
instructions)

12. I-765, Employment Authorization Document, if appropriate and
necessary, fully completed, signed, and: (NOTE: no additional fee
required if concurrently filed with I-485 application):

Two photos (lightly write your name in pencil on the reverse)

Copy of I-485 Receipt Notice (if not concurrently filed)

Copy of passport biographical page (including passport expiration date)

Copy of all nonimmigrant visa stamps from passport

Copy of Form I-94

Copy of I-797 Approval Notice(s) for current immigration status

13. I-131, Advance Parole, if appropriate and necessary, fully
completed, signed, and: (NOTE: no additional fee required if
concurrently filed with I-485 application):

Two photos (lightly write your name in pencil on the reverse)

Letter requesting advance parole

Copy of I-485 Receipt Notice (if not concurrently filed)

Copy of passport biographical page (including passport expiration date)

Copy of all nonimmigrant visa stamps from passport

Copy of Form I-94

Copy of I-797 Approval Notice(s) for current immigration status

***D. Dependent(s) included in adjustment application---prepare a
separate package for each dependent:***

14. I-485 Adjustment of Status Application, fully completed, signed,
w/fee (\$930; if under 14: \$600 if concurrently

filed with primary's I-485, otherwise subject to full adult rate of
\$930 if filed separately) and:

Two photos (lightly write your name in pencil on the reverse)

Copy of primary's I-140 and/or I-485 Approval Notice or Receipt Notice
(if not concurrently filed)

Biometric Fee (\$80), if age 14 and older

I-693, Medical Exam (**must** be completed by a USCIS-designated
physician)

G-325A, Biographical Information (complete if age 14 and older)

Copy of birth certificate

Copy of passport biographical page (including passport expiration date)

Copy of all nonimmigrant visa stamps from passport

Copy of Form I-94

Copy of I-797 Approval Notice(s) for current immigration status

> Letter of financial support (letter from primary applicant indicating
> job title, lab, salary and employment
>
> dates, as well as a statement that the primary applicant will continue
> to support their dependents if LPR granted.)

Immigration History w/supporting evidence (optional)

Marriage Certificate (if applicable)

Criminal History (if applicable; refer to page 3 of the USCIS
instructions)

15. I-765, Employment Authorization Document, if appropriate and
necessary, fully completed, signed, and: (NOTE: no additional fee
required if concurrently filed with I-485 application):

Two photos (lightly write your name in pencil on the reverse)

Copy of I-485 Receipt Notice (if not concurrently filed)

Copy of passport biographical page (including passport expiration date)

Copy of all nonimmigrant visa stamps from passport

Copy of Form I-94

Copy of I-797 Approval Notice(s) for current immigration status

16. I-131, Advance Parole, if appropriate and necessary, fully
completed, signed, and: (NOTE: no additional fee required if
concurrently filed with I-485 application)

Two photos (lightly write your name in pencil on the reverse)

Letter requesting advance parole

Copy of I-485 Receipt Notice (if not concurrently filed)

Copy of passport biographical page (including passport expiration date)

Copy of all nonimmigrant visa stamps from passport

Copy of Form I-94

Copy of I-797 Approval Notice(s) for current immigration status

*Note that the I-485 application is your personal application, not the
NIH's. The above sections (C and D) assist you in assembling your*

*I-485 package, but do **NOT** take the place of USCIS instructions. Be
sure to read **ALL** instructions attached to the forms and include all
necessary items. Copy the I-485 package for your records.*

**Submit this form and required evidence via HAND-CARRY or EXPRESS MAIL
to:**

**Division of International Services /ORS**

**31 Center Drive, MSC 2028**

**Building 31, Rm B2B07**

**Bethesda, MD 20892-2028**

LAWFUL PERMANENT RESIDENT (LPR) PETITION WORKSHEET

[To be completed by the Beneficiary]{.underline}

UNALTERED ORIGINAL DOCUMENTS

+----------------------------+---------------------------------------+---+
| > TO THE UNITED STATES     |                                       |   |
| > CITIZENSHIP AND          |                                       |   |
| > IMMIGRATION              |                                       |   |
| > SERVICES/FDA/NIH         |                                       |   |
+----------------------------+---------------------------------------+---+
| > Copies of documents      |                                       |   |
| > submitted are exact      |                                       |   |
| > copies of unaltered      |                                       |   |
| > original documents. I    |                                       |   |
| >                          |                                       |   |
| > understand that I may be |                                       |   |
| > required to submit       |                                       |   |
| > original documents to an |                                       |   |
| > Immigration or           |                                       |   |
| >                          |                                       |   |
| > Consular official at a   |                                       |   |
| > later date.              |                                       |   |
+----------------------------+---------------------------------------+---+
|                            |                                       |   |
+----------------------------+---------------------------------------+---+
|                            | Print Name of Beneficiary             |   |
+----------------------------+---------------------------------------+---+
|                            |                                       |   |
+----------------------------+---------------------------------------+---+
|                            | Signature of Beneficiary              |   |
+----------------------------+---------------------------------------+---+
|                            |                                       |   |
+----------------------------+---------------------------------------+---+
|                            | Date Signed                           |   |
+----------------------------+---------------------------------------+---+

**TRANSLATION OF FOREIGN LANGUAGE DOCUMENT(S)**

(Translations must be done by someone other than yourself *or immediate
family members*.

+---+-------------------+---+-----------------------+---------------+---+
| > |                   |   |                       | , hereby      |   |
|   |                   |   |                       | certify that  |   |
| I |                   |   |                       | I am          |   |
| , |                   |   |                       |               |   |
+---+-------------------+---+-----------------------+---------------+---+
| > |                   |   |                       | language into |   |
|   |                   |   |                       | English and   |   |
| c |                   |   |                       |               |   |
| o |                   |   |                       |               |   |
| m |                   |   |                       |               |   |
| p |                   |   |                       |               |   |
| e |                   |   |                       |               |   |
| t |                   |   |                       |               |   |
| e |                   |   |                       |               |   |
| n |                   |   |                       |               |   |
| t |                   |   |                       |               |   |
| > |                   |   |                       |               |   |
|   |                   |   |                       |               |   |
| t |                   |   |                       |               |   |
| o |                   |   |                       |               |   |
| > |                   |   |                       |               |   |
|   |                   |   |                       |               |   |
| t |                   |   |                       |               |   |
| r |                   |   |                       |               |   |
| a |                   |   |                       |               |   |
| n |                   |   |                       |               |   |
| s |                   |   |                       |               |   |
| l |                   |   |                       |               |   |
| a |                   |   |                       |               |   |
| t |                   |   |                       |               |   |
| e |                   |   |                       |               |   |
| > |                   |   |                       |               |   |
|   |                   |   |                       |               |   |
| f |                   |   |                       |               |   |
| r |                   |   |                       |               |   |
| o |                   |   |                       |               |   |
| m |                   |   |                       |               |   |
| > |                   |   |                       |               |   |
|   |                   |   |                       |               |   |
| t |                   |   |                       |               |   |
| h |                   |   |                       |               |   |
| e |                   |   |                       |               |   |
+---+-------------------+---+-----------------------+---------------+---+
| > |                   |   |                       |               |   |
|   |                   |   |                       |               |   |
| t |                   |   |                       |               |   |
| h |                   |   |                       |               |   |
| a |                   |   |                       |               |   |
| t |                   |   |                       |               |   |
| > |                   |   |                       |               |   |
|   |                   |   |                       |               |   |
| t |                   |   |                       |               |   |
| h |                   |   |                       |               |   |
| e |                   |   |                       |               |   |
| > |                   |   |                       |               |   |
|   |                   |   |                       |               |   |
| a |                   |   |                       |               |   |
| t |                   |   |                       |               |   |
| t |                   |   |                       |               |   |
| a |                   |   |                       |               |   |
| c |                   |   |                       |               |   |
| h |                   |   |                       |               |   |
| e |                   |   |                       |               |   |
| d |                   |   |                       |               |   |
| > |                   |   |                       |               |   |
|   |                   |   |                       |               |   |
| i |                   |   |                       |               |   |
| s |                   |   |                       |               |   |
| > |                   |   |                       |               |   |
|   |                   |   |                       |               |   |
| t |                   |   |                       |               |   |
| h |                   |   |                       |               |   |
| e |                   |   |                       |               |   |
| > |                   |   |                       |               |   |
|   |                   |   |                       |               |   |
| a |                   |   |                       |               |   |
| c |                   |   |                       |               |   |
| c |                   |   |                       |               |   |
| u |                   |   |                       |               |   |
| r |                   |   |                       |               |   |
| a |                   |   |                       |               |   |
| t |                   |   |                       |               |   |
| e |                   |   |                       |               |   |
| > |                   |   |                       |               |   |
|   |                   |   |                       |               |   |
| t |                   |   |                       |               |   |
| r |                   |   |                       |               |   |
| a |                   |   |                       |               |   |
| n |                   |   |                       |               |   |
| s |                   |   |                       |               |   |
| l |                   |   |                       |               |   |
| a |                   |   |                       |               |   |
| t |                   |   |                       |               |   |
| i |                   |   |                       |               |   |
| o |                   |   |                       |               |   |
| n |                   |   |                       |               |   |
| > |                   |   |                       |               |   |
|   |                   |   |                       |               |   |
| o |                   |   |                       |               |   |
| f |                   |   |                       |               |   |
| > |                   |   |                       |               |   |
|   |                   |   |                       |               |   |
| t |                   |   |                       |               |   |
| h |                   |   |                       |               |   |
| e |                   |   |                       |               |   |
| > |                   |   |                       |               |   |
|   |                   |   |                       |               |   |
| o |                   |   |                       |               |   |
| r |                   |   |                       |               |   |
| i |                   |   |                       |               |   |
| g |                   |   |                       |               |   |
| i |                   |   |                       |               |   |
| n |                   |   |                       |               |   |
| a |                   |   |                       |               |   |
| l |                   |   |                       |               |   |
| > |                   |   |                       |               |   |
|   |                   |   |                       |               |   |
| d |                   |   |                       |               |   |
| o |                   |   |                       |               |   |
| c |                   |   |                       |               |   |
| u |                   |   |                       |               |   |
| m |                   |   |                       |               |   |
| e |                   |   |                       |               |   |
| n |                   |   |                       |               |   |
| t |                   |   |                       |               |   |
| ( |                   |   |                       |               |   |
| s |                   |   |                       |               |   |
| ) |                   |   |                       |               |   |
| . |                   |   |                       |               |   |
+---+-------------------+---+-----------------------+---------------+---+
|   |                   |   |                       |               |   |
+---+-------------------+---+-----------------------+---------------+---+
|   |                   |   |                       |               |   |
+---+-------------------+---+-----------------------+---------------+---+
|   |                   |   | Print Name & Title of |               |   |
|   |                   |   | Translator            |               |   |
+---+-------------------+---+-----------------------+---------------+---+
|   |                   |   |                       |               |   |
+---+-------------------+---+-----------------------+---------------+---+
|   |                   |   | Signature of          |               |   |
|   |                   |   | Translator            |               |   |
+---+-------------------+---+-----------------------+---------------+---+
|   |                   |   |                       |               |   |
+---+-------------------+---+-----------------------+---------------+---+
|   |                   |   | Date Signed           |               |   |
+---+-------------------+---+-----------------------+---------------+---+