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Get Medical Form For Visa Application

O, IL 60603 Tel. no. (312) 583-0621 Fax no. (312) 583-0647 Website: www.chicagopcg.com APPLICATION FOR IMMIGRANT VISA PLEASE TYPE OR PRINT ANSWERS LEGIBLY IN THE SPACES PROVIDED (IF NOT APPLICABLE WRITE (N/A) 1. NAME AS WRITTEN IN PASSPORT 2. LAST NAME (surname or family name) 3. FIRST NAME (all given names) APPLICANT'S PHOTOGRAPH 2 in. x 2 in. 5. SEX MALE 4. MIDDLE NAME 7. DATE OF BIRTH (dd/mm/yyyy) 9. FEMALE 6. CITIZENSHIP CIVIL STATUS 1. Picture taken within the past 6 months.

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