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: April 22, 2019
 

 
Copyright 2019  Perez & Associates   All Rights Reserved.