ate/province, and country where you were born. 19.a. Citv/TownNilla e of Birth 19.b. State/Province of Birth 19.c. Country of Birth =IS 20. Datc of Birth (mm/dd/yyyy) I Information About Your Last Arrival in the United States 21.a. Form 1-94 Arrival-Departure Record Number (if any) 21.b. Pass ort Number of Yo