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Kreyòl Creole
Konplete yon sèl fòm pou chak kay, epi bay plis enfòmasyon posib.
Complete only one form per household, and provide as much information as possible.
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1.
Premye non
First name
(Required.)
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2.
Siyati
Last name
(Required.)
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3.
Adrès email (siw pa genyen tape: x)
Email (If you don’t have an email please type: x)*
(Required.)
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4.
Nimewo telefòn (XXX) XXX-XXXX
Phone Number
(Required.)
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5.
Ki adrès lakay ou: Ri, Vil, NY
What is your address: Street, City, NY
(Required.)
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6.
Kilè ou rive nan peyi Etazini?
What date did you arrive in the United States? Example: 12/31/2005
(Required.)
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7.
Ki estati imigrasyon ou genyen nan moman an?
What is your current immigration status?
(Required.)
DT Parolè (Kiben, Ayisyen, Nikaragwen, ak Venesyelyen)
DT Parolee (Cuban, Haitian, Nicaraguan, and Venezuelan)
Program pawòl imanitè
Haitian Humanitarian Parolee (HHP)
Kiben/ Ayisyen ki vini
Cuban/Haitian Entrant (CHE)
Refijye
Refugee (REF)
Azil
Asylee (ASY)
Viktim trafik moun
Victim of Human Trafficking (VOT)
8.
Ki nivo anglè ou? (chwazi youn)
What is your English level? (chose one)
Pa pale anglè
None
Yon ti anglè
Minimal
Kapab pale anglè
Good
Pale bon anglè
Fluent
9.
Mwen bezwen al travay nan 3 mwa kap vini la:
I need to work in the next 3 months:
Wi
Yes
Non
No
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10.
Dispoze pou travay nan premye nivo:
I am willing to work an entry level position:
(Required.)
Wi
Yes
Non
No
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11.
Eskew aplike pou otorization travay deja?
Have you applied for your EAD?
(Required.)
Wi
Yes
Non
No
12.
Si wi, eske ou resevwa otorizasyon travay ou deja?
If yes, have you received your EAD?
Wi
Yes
Non
No
13.
Ki lòt èd ou bezwen? (Ekri nan pati blan)
What help do you need? (Fill in the blank)
Tanpri ba nou jiska 2 semèn pou nou kontakte ou. Nap kontaktew a pati de enfòmasyon ou bay nan fòm sa. Mèsi pou konpreyasyon ou!
Please allow us up to two weeks to contact you. We will contact you according to the information provided on the list. Thank you for understanding!