Your Full Name:
 

Country of Residence:
 

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Email Address:
 

Date of Birth - Month / Day / Year:
 

Any temporary or permanent civil protection order or restraining order issued against you?
If none, type no, else provide details below.
 

Any Federal, State, or local arrest or conviction for homicide, murder, manslaughter, assault, battery, domestic violence, rape, sexual assault, abusive sexual contact, sexual exploitation, incest, child abuse or neglect, torture, espionage, holding hostage, involuntary servitude, human trafficking, kidnapping, abduction, unlawful criminal restraint, false imprisonment, or stalking?
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Any Federal, State, or local arrest or conviction for-- (I) solely, principally, or incidentally engaging in prostitution; (II) a direct or indirect attempt to procure prostitutes or persons for the purpose of prostitution; or (III) receiving, in whole or in part, of the proceeds of prostitution.
If none, type no, else provide details below.
 

Any Federal, State, or local arrest or conviction for offenses related to controlled substances or alcohol.
If none, type no, else provide details below.
 

Your marital history, including whether you are single, currently married, whether you have been previously married and how many times, how your previous marriages were terminated and the date of termination, and whether you have previously sponsored an alien to whom you where engaged or married.
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The ages if any of your children who are under the age of 18.
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All States and countries in which you have resided since you where 18 years of age
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I CERTIFY AND ATTEST, under penalty of perjury and false statement, that my above CLIENT BACKGROUND INFORMATION IS TRUE AND COMPLETE. I also give my permission to Dominican Republic Websites C por A to release and provide this information in any format to all interested foreign ladies available. I have provided any necessary additional truthful documentation to all questions answered ‘Yes’ above. I hereby WAIVE ANY PRIVACY RIGHTS FROM RELEASE OF THIS INFORMATION. I ALSO HEREBY RELEASE AND HOLD HARMLESS AND FOREVER DISCHARGE Dominican Republic Websites C por A FROM ANY AND ALL LIABILITIES arising from my release of this information and any use of it.

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