Important Information for U.S.A. Clients! Please read the following information carefully. 5 January 2006 President Bush signed the new law about dating agencies (International Marriage Broker Regulation Act of 2005), which became operational from 6 March 2006. What does it mean for you? According to this law, U.S. citizens and legal residents that use dating agencies to meet someone from abroad are obliged to provide a Personal Disclosure statement before they can start communication. In other words, before you can contact a foreign lady (or gentleman), you need to send them your Personal Disclosure statement and receive their agreement to get to know you. This is done because foreign residents have fewer opportunities to find out about you than local people, and some unscrupulous individuals used it in the past to their advantage. Personal Disclosure provides non-USA clients with some information about you they otherwise would not get. What information has to be disclosed? You need to answer questions about your marital and criminal history, dependent children under 18 years old and the states where you lived. The exact questions of the Personal Disclosure statement can be found on the bottom of this page. What will be done with this information? The information will be made available to clients that want to access your Disclosure information by clicking on that file in your profile. Do I really have to do it? Yes. Obeying this law is mandatory for ALL international dating agencies, regardless of which country they operate from. If a dating agency does NOT comply with this law, your relationship can be found invalid and your foreign girlfriend (or boyfriend) may be refused an entrance visa to the U.S. In other words, if you meet someone through an agency that does NOT require from you to fill in a Personal Disclosure statement, you may have problems when your foreign friend applies for an entrance visa to the U.S., which may result in a failure of your relationship. If I meet someone here, will I be able to bring her into the U.S.? We do our best to ensure the relationships entered through our agency are legitimate and you can bring your foreign girlfriend (or boyfriend) into the U.S. without problems. Thank you for your cooperation and support in this matter. Personal Disclosure Statement Please answer "Yes" or "No" to the following questions, or choose an appropriate option. If you answered "Yes", you can provide additional information in the space provided. Answering "Yes" does NOT disqualify you from being able to apply for a fiancee visa or marry a foreigner. Have you been married before? No Yes If yes, please include the information on how the marriage was terminated, and the year of termination: 1st marriage divorced widowed still married annulled 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2nd marriage divorced widowed still married annulled 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 3st marriage divorced widowed still married annulled 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 4th marriage divorced widowed still married annulled 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 5th marriage divorced widowed still married annulled 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 6th marriage divorced widowed still married annulled 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Do you have any children under the age of 18? No Yes If yes, please include their Year of Birth 1st child 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2nd child 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 3st child 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 4th child 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 5th child 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 6th child 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Have you ever sponsored an alien to whom you were engaged or married? (For example, if you have applied for a fiancee or spouse visa for a foreign citizen) No Yes Are you married currently? (If you are not legally divorced, then you are legally married) No Yes If yes, please specify: living together with my spouse separated legally separated in the process of divorce separated for more than 1 year separated for more than 2 years separated for more than 3 years separated for more than 5 years Have you ever had any temporary or permanent civil protection order or restraining order issued against you? No Yes If yes, please specify: temporary restraining order temporary restraining order, which has since expired mutual temporary restraining order during divorce mutual temporary restraining order mutual restraining order other 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Have you ever been arrested or convicted for offenses related to controlled substances or alcohol? No Yes If yes, please specify: driving under influence drinking under age drinking in public other 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 found not guilty charges dropped case dismissed found guilty other Have you ever been arrested or convicted for prostitution-related offences: No Yes If yes, please specify: engaging in prostitution attempt to procure prostitutes receiving proceeds of prostitution 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 found not guilty charges dropped case dismissed found guilty other Have you ever been arrested or convicted for any of the following offences: (abduction, abusive sexual contact, assault, battery, child abuse or neglect, domestic violence, false imprisonment, holding hostage, homicide, incest, involuntary servitude, kidnapping, manslaughter, murder, peonage, rape, torture, trafficking, sexual assault, sexual exploitation, slave trade, stalking, unlawful criminal restraint) No Yes If yes, please specify: abduction abusive sexual contact assault battery child abuse or neglect domestic violence false imprisonment holding hostage homicide incest involuntary servitude kidnapping manslaughter murder peonage rape torture trafficking sexual assault sexual exploitation slave trade stalking unlawful criminal restraint 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 found not guilty charges dropped case dismissed found guilty other Please supply your name and address (EXACTLY as in your documents; i.e. "Joseph", not "Joe") This information is for Personal Disclosure Statement only; it will NOT appear anywhere else. Please change the pre-filled information if necessary. First Name Surname County City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip code Please list all states and countries where you lived since the age of 18: (Press CTRL on your keyboard to select more than one option) USA States: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Countries: If you only lived in the United States, you don't have to select countries Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua And Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia And Herzegowina Botswana Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Colombia Comoros Congo Cook Islands Costa Rica Cote D'ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia European Union Falkland Islands (malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-bissau Guyana Haiti Heard Island And Mcdonald Islands Holy See (vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakstan Kenya Kiribati Korea Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Kitts And Nevis Saint Lucia Saint Vincent And The Grenadines Samoa San Marino Sao Tome And Principe Saudi Arabia Senegal Serbia And Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania Thailand Timor-leste Togo Tokelau Tonga Trinidad And Tobago Tunisia Turkey Turkmenistan Turks And Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands Yemen Zambia Zimbabwe Please list all zip codes where you lived in the USA since the age of 18: Separate the zip codes by commas Comments: Please include any relevant information you could not include above here: Signatures of both US Citizen and non Us Citizen ___________________________________ signature date ____________________________________ signature date