IMMIGRATION QUESTIONNAIRE

I - CANDIDATE: 1. Personal data Full name (as stated in the passport): "ationalit#: *ate o' (irth: $assport num(er: Issuin4 pla&e (&it#5&ountr#): 7ome address a(road: JOSE MIGUEL VELASQUE $E%UA"A +,)+,)+-./ 12/31+LIMA5$E%U U!IGA $la&e o' (irth (&it#)&ountr#): Marital Status: Issuin4 date: Validit# date: A%EQUI$A SOL0E%O +/),+)2,++ +/),+)2,+6

AV8 9%ASIL -:51 JESUS MA%IA5 LIMA ; $E%U ("85 street5 apt85 &it#5 <ip &ode and &ountr#) 9E%"A9E FELI> VELASQUE $E%UA"A ELSA JUA"A $E%UA"A U!IGA VILLA"UEVA VIGIL

Father=s 'ull name: Father=s nationalit#: Mother=s 'ull name: Mother=s nationalit#:

Braz l an Cons!late "# t$ and #o!ntr$% a&road '(ere t(e ) sa s(all &e sent to:

*. Instr!#t on *.1 + ,( S#(ool $eriod: Full name o' the s&hool: ?it# and &ountr#: +--6;2,,, LI9E%0A*O% ?AS0ILLA A%EQUI$A ; $E%U

*.* Te#(n #al S#(ool $eriod: Full name o' the s&hool: ?it# and &ountr#: Full name o' the &ourse:

*.- Un )ers t$ $eriod: Full name o' the uni@ersit#: ?it# and &ountr#: Full name o' the &ourse: 2,,+ ; 2,,1 U"IVE%SI*A* "A?IO"AL *E SA" AGUS0I" A%EQUI$A ; $E%U I"GE"IE%AA GEOFASI?A

*.. Post-,rad!at on

$eriod: Full name o' the uni@ersit#: ?it# and &ountr#: Full name o' the &ourse:

*./ Ot(er #o!rses $eriod: Full name o' the institution: ?it# and &ountr#: Full name o' the &ourse:

-. Pro0ess onal &a#1,ro!nd -.1 $eriod: Full name o' the &ompan#: ?it# and &ountr#: $osition: *e@eloped a&ti@ities: 2,,6 ; 2,,: $E%U$E0%O LIMA ; $E%U 9ASE *E *A0OS C!rrent Salar$ "2ont(l$ ,ross%:

A?0UALI A?IB" *E FI?7AS SASMI?AS

-.*. $eriod: Full name o' the &ompan#: ?it# and &ountr#: $osition: *e@eloped a&ti@ities: 2,,: C A LA FE?7A SAE>$LO%A0IO" LIMA; $E%U ?O"0%OL *E ?ALI*A* %E$O%0ES *IA%IOS5 ?O"0%OL *E *ISE!O5 A*QUISI?IB" D $%O?ESAMIE"0O *E U$7OLES D %EF%A??IO"ES

-.$eriod: Full name o' the &ompan#: ?it# and &ountr#: $osition: *e@eloped a&ti@ities:

/.E34la n t(e 1no'led,e o0 lan,!a,es "s4ea1 n,5 read n, and 'r t n,%: ES$A!OL (speaEin45 readin4 and Fritin4) I"GLES (speaEin45 readin4 and Fritin4) II 6 DEPENDENTS "onl$ t(ose '(o ' ll #o2e to Braz l%:

1. S4o!se: Full name (as stated in the passport): "ationalit#: *ate o' (irth: $assport num(er: Issuin4 pla&e (&it#5&ountr#): 7ome address a(road: ("85 street5 apt85 &it#5 <ip &ode and &ountr#) Father=s 'ull name: Mother=s 'ull name: Issuin4 date: Validit# date: $la&e o' (irth (&it#)&ountr#):

*. C( ldren: Full name (as stated in the passport): "ationalit#: *ate o' (irth: $assport num(er: Issuin4 pla&e (&it#5&ountr#): 7ome address a(road: ("85 street5 apt85 &it#5 <ip &ode and &ountr#) Issuin4 date: Validit# date: $la&e o' (irth (&it#)&ountr#):

Full name (as stated in the passport): "ationalit#: *ate o' (irth: $assport num(er: Issuin4 pla&e (&it#5&ountr#): 7ome address a(road: ("85 street5 apt85 &it#5 <ip &ode and &ountr#) Issuin4 date: Validit# date: $la&e o' (irth (&it#)&ountr#):

Full name (as stated in the passport): "ationalit#: *ate o' (irth: $assport num(er: Issuin4 pla&e (&it#5&ountr#): 7ome address a(road: ("85 street5 apt85 &it#5 <ip &ode and &ountr#) Issuin4 date: Validit# date: $la&e o' (irth (&it#)&ountr#):