Foreign National Information System Data Gathering Form

Foreign National Information System Data Gathering FormAs a state agency within the State of North Carolina, the Department of Correction is required to obtain therequested information on all persons who are not U.S. Citizens and are providing services to the Department.Please complete the below information and sign the back of this form verifying the information provided isaccurate. Complete the information appropriate for your status.Section 1 InformationSalutation (circle): Mr. or Mrs. or Ms.First Name:Middle Name:Last Name:Suffix (i.e. Sr. or Jr):Your SSN / ITIN:Applied for SSN / ITIN (circle): YES or NOForeign Taxpayer ID:Student Type:Not NeededTrainee Type:Not NeededAgency Use Only:Payroll Number: 033Facility Number (4 digit RCC #):Code (type-expiration):Section 2 InformationDate of Birth:Marital Status (circle): MARRIED or SINGLEIs Your Spouse in the USA? (circle): YES or NOIs Your Spouse Working in theUSA? (circle): YES or NOTotal Number of Dependents (not including spouse):Number of Dependents Who Were with You in theU.S. at Some Time in the Calendar Year:Number of Dependents Who Are U.S. Citizens orResidents:Home Phone (include area code):Day Phone (include area code):Fax (include area code):Agency Use Only-Agency Email Address:Date First in USA:Section 3 InformationU.S. Address Line 1:U.S. Address Line 2:U.S. Address Line 3:City:State:Zip code:Foreign Address Line 1:Foreign Address Line 2:Foreign Address Line 3:Foreign City:Province/Region:Postal Code:Country of Residence Address: