IM1Ai(Expires 11/30/13)

Department of Homeland Security

U S Citizenship and Immigration Service

Active Security Clearance Application Form

Section A Personal Details

Family Name

Given Names
AFFIX RECENT
AFFIX RECENT
PASSPORT
PASSPORT
Name as in Passport
PHOTOGRAPH
PHOTOGRAPH
HERE
HERE
Other Names you are known by or have ever been known by

Gender Male Female Date of Birth / /

Father's Name

Your Address:

Work

Home

Telephone (daytime) Telephone (Evening)

Fax Email

Application fees is $ 655 ( Proof of payment from current location must be presented)
Occupation

Place of birth ( city, town or village, state or province, country)

Nationality

Passport Details:

Number Country

Expiry Date / /

Have you any criminal or civil action pending?

Yes Give details below

No

Section B Applicant's Fingerprints

If you are in the US, your finger prints must be taken at the nearest
Homeland Security office.

If you are applying from outside the US, then kindly wet your right thumb
In an Ink and place on the box given by the side.
Thumb print

Section C Declaration

I declare i have provided true and correct answers to the questions in the form .

Signature of applicant Date / /