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Y all applicants (Type or print in black ink) PART 1. Family Name (in capital letters) First Name Present Address: Number and Street City or Town Date of Birth (mm/dd/yyyy) Place of Birth City or Town A-Number Middle Name State Zip Code Country of Birth Country of Citizenship PART 2. I have been declared inadmissible or ineligible for adjustment of status under the following section(s) of 212(a) of the Immigration and Nationality Act (INA): (NOTE: Sections 212(a)(4), 212(a)(5), and 2.

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