IMMIGRATION Law Perez & Associates

Tampa, Florida | 813.254.VISA | fax 813.254.0311

Case e-Valuation Order Form

Perez & Associates
1303 N. Armenia Avenue
Tampa, Florida 33607

Email | voice 813.254.VISA (8472) | fax 813.254.0311

Credit Cards Accepted
(Visa & MasterCard)

Your information is submitted via our Secure Server
using the latest in SSL 256-bit data encryption technology.

If you would like us to evaluate your case kindly complete
the form below. Your credit card will be charged $300.00.

Please tell us how to contact you...

First Name
Middle Name
Last Name
Phone
Fax
Email
US Address Information
Address
City
State
Zip
Outside the US Address Information
Address 1
Address 2
City
State / Province
Zip / Postal Code
Country
Please provide us with information about you and your case...
Date of Birth
Place of Birth (City/County)
Marital Status (select one)	Married	Single	Separated	Divorced
Number of Unmarried Children under the age of 21
Immigration File Number
Date of Last Entry into the US
Place of Last Entry into the US
Date authorization to stay in the US expires
Passport Expiration Date
Are you a Permanent Resident of the United States ?	YES	NO
Date you became a Permanent Resident...
Since becoming a Permanent Resident have you been out of the US for more than 6 months at a time ?	YES	NO
Describe your current situation in detail...
Describe your immigration objectives...
If you have ever been arrested - please provide information in the boxes below. Include all Criminal Traffic Arrests such as DUI and Reckless Driving...
Arrest 1 - include Date, Location (City/State), Charge and Final Disposition...
Arrest 2 - include Date, Location (City/State), Charge and Final Disposition...
Arrest 3 - include Date, Location (City/State), Charge and Final Disposition...
Arrest 4 - include Date, Location (City/State), Charge and Final Disposition...

Please provide us with your billing information.

Your credit card will be charged $300.

(all field are required)

Name
Address
City
State / Province
Zip / Postal Code
Country
Day phone
Eve phone
Email
Credit Card
Card Number		(no spaces or hyphens)
Expiration
For your security, we ask for the 3 digit Card Identification Number located on the back of your card.

For security purposes please copy the digits
from the image above, into the box below...

Last revised: March 13, 2020