Client Background Information Disclosure Form

Transpacific Marriage Agency (TMA)
Background Information Disclosure Form

U.S. clients must print out this form and send it to TMA.

U.S. law requires U.S. clients to provide the following background information (attach extra sheets if necessary):

Full name:

Address with postal/zip code:

Telephone:

Email address:

Date of birth (mo/day/yr):

If you answer "Yes" to any of the questions below, please provide a detailed statement of explanation or any necessary additional documentation (including but not limited to copies of court orders, judgments, convictions and arrest records). If necessary, please send any additional documentation. You are not required to include marriage certificates, birth certificates or divorce papers.

Are there now, or have there ever been, any temporary or permanent civil protection orders, restraining orders, emergency protective orders, or domestic violence orders, issued against you by any court or other governmental authority?

Yes

Details:

Have you ever been arrested OR convicted by any Federal, State or Local authority for homicide, murder, manslaughter, assault, battery, domestic violence, rape, sexual assault, abusive sexual contact, sexual exploitation, incest, child abuse or neglect, torture, trafficking, peonage (compelling persons to perform labor to pay off a debt), holding hostage, involuntary servitude, slave trade, kidnapping, abduction, unlawful criminal restraint, false imprisonment, or stalking?

Yes

Details:

Have you ever been arrested OR convicted by any Federal, State or Local authority for (a) solely, principally, or incidentally engaging in, prostitution? OR (b) a direct or indirect attempt to procure prostitutes or persons for the purpose of prostitution? OR (c) receiving, in whole or in part, proceeds of prostitution?

Yes

Details:

Have you ever been arrested OR convicted by any Federal, State or Local authority for any offense(s) related to controlled substances or alcohol?

Yes

Details:

What is your current marital status?		Married
		Single
		Divorced
		Widowed

Have you been previously married? If "Yes," please provide details, including how many times you were married, how marriages were terminated and the date(s) of termination.

Yes

Details:

Have you at any time previously sponsored an alien to whom you were engaged or married?

Yes

Details:

Please list the ages of all of your children, whether biological or adopted, who are under 18 years of age.

Details:

Please list all states in the United States and all countries in which you have resided since you were 18 years of age:

Details:

I hereby certify and attest, under penalty of perjury and false statement, that my above client background information is true and complete. I understand that TMA is mandated to collect from the gentleman client the above background information and also to conduct an electronic search on the National Sex Offender public registry and state public registry (http://www.nsopr.gov/). This information and the search results will be made available to any ladies interested in meeting U.S. men. I also give my permission to TMA to release and provide this information in any format to any interested foreign ladies. 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 TMA from any and all liabilities arising from my release of this information and any use of it.

Signature of U.S. client:

Date: