H1B Application

Personal Information First name Middle name Last name Date of birth Email Phone Current address City State/province/region Country Country of citizenship City of birth State/province/region of citizenship Passport number Date passport issued Date passport expires Issuing country

Job Function Information Estimated start date of employment Position title of WFBMC job Sponsoring WFBMC department Base salary for WFBMC job Brief summary of position duties (2-4 sentences)

H 1B Questionnaire

Do you currently reside in the U.S.? No Yes

Are you currently classified as an H-1B nonimmigrant? No Yes

Do you have any dependents who will be included in your H-1B application? If yes, you will need to complete Form I-539 and submit it to International Services so that it can be submitted with the H-1 petition. Please be aware that this is considered a personal application and is not associated with WFBMC. No Yes

Are you, or any person included in the H-1B application, an applicant for an immigrant visa or adjustment of status to permanent residence? No Yes

Has an immigrant petition ever been filed for you or any other person included in the H-1B application? No Yes

Have you or any other person included in the H-1B petition ever been convicted of a criminal offense since last entering the U.S.? No Yes

Have you or any person listed in the H-1B application ever done anything that violated the terms of the nonimmigrant status you presently hold? No Yes

Are you currently residing in the U.S. in J-1/J-2 status, or have you ever held this status in the past? No Yes

Are you currently employed in the U.S. in H-1B status by an employer other than WFBMC? No Yes

Name of WFBMC department with which you are/will be working If you will be applying for an H-1 visa outside of the U.S., please provide the location of the U.S. Embassy/Consulate where you will be scheduling your visa interview.

MyAtriumHealth

H-1B Application