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Questions marked with an * are required Exit Survey
 
 
Personal Information
 
 
 
* First Name : 
* Last Name : 
* Address 1 : 
   Address 2 : 
* City : 
* State : 
* Zip : 
* Phone : 
* Email Address : 
 
 
 
Date of birth:
 
 
 
First Language:
   
 
 
 
Secondary Language:
   
 
 
Use of the English Language:
not well fairly well well very well
How well do you speak English?
How well do you write English?
How well do you read English?
 
 
 
Marital Status:
 
 
 
Spouse Name
   
 
 
 
Spouse Age:
   
 
 
 
# of children:
   
 
 
 
Demographics:
 
 
 
Passport#:
   
 
 
 
Country Issued:
   
 
 
 
Country Born
   
 
 
 
Country of Citizenship:
   
 
 
 
Visa Status:
   
 
 
 
Visa Type:
 
 
 
Visa Expiration
 
 
 
Background
 
 
 
Have you ever been arrested?
 
 
 
If you have been arrested, were you convicted?
 
 
 
Brief Explanation:
   
 
 
 
Have you used or currently using illegal drugs?
 
 
 
If you have used illegal drugs, brief explanation, including dates.
   
 
 
 
Health
 
 
 
Are you physical or emotionally fit to participate in our program?
 
 
 
Do you have any special needs requirements?
 
 
 
If so, Please explain.
   
 
 
 
Financial
 
 
 
Who will provide your own personal spending money of $1,200? (self, sponsor)
 
self
 
sponsor
 
 
 
If sponsor, please provide name, phone and email:
 
 
 
First Name : 
Last Name : 
Phone : 
Email Address :