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s 21.a. 21.b. 21.e. 21.d. Form I-94 Arrival Ito Passport Number Departure Record Number (if any
tate/province, and country where you were born. 19.a. CityfrownNillage of Birth 19.b. State/Province of Birth 19.c. Country of Birth 20. Date of Birth (mm/dcVyyyy) Information About Your Last Arrival in the United States 21.a. 21.b. 21.e. 21.d. Form I-94 Arrival Ito Passport Number Departu
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un+ry I q quc. LAS reCords in tout ae coltntrq -(54; /co mmottai ail- tines alt lines Santa. rc, Tt3t EFTA01721808 Alias Names (2) Dates of Birth (1) IDs (2) Passport Passport Citizenship (2) Sweden Iran Nationality (0) Place of Birth (0) Countries of Residence (1) Sweden Emails (1)
an oath (print, type or stamp commissioned name of notary public) V:CKI L. WARD t Commission Y 6$ 232601 P., Expires °clots 12, 2022 Sne 1 bit; Ito? rye hivrxe W-114-7019 Personally known V or produced identification Type of identification produced Service • Integrity • Respect • Quality EFT
0435(14)(b), 944.607(13)(b), 985.4815(13)(a), Florida Statutes} Month of Birth I must reregister In the months of: Month I must reregister of Birth In the months of: Jan Jan, April, July & Oct Fob, May, Aug, & Nov July Jan, April, July & Oct Aug Feb. May, Aug, & Nov Feb Mar Mar, June. Se
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United States
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