Immigration Status Information Release Authorization

I hereby authorize the release of my immigration status information as described below. I understand this information may be disclosed to authorized representatives for the purposes specified.

Personal Information

Full Name

Date of Birth

Alien Registration Number (if any)

Current Address

Information to be Released

Immigration Status

Visa Category

Dates of Status

Other (specify below)

Recipient of Information

Name/Organization Contact Information

Purpose of Release

Authorization & Signature

I understand that this authorization is voluntary and that I may revoke it at any time by providing written notice. This authorization expires on the date specified below or in one year if left blank.

Signature

Date

Expiration Date