Imbra

Client Information

International Marriage Broker Regulation Act of 2005

Client Background Information

SPECIAL NOTE: Under new federal legislation effective March 06, 2006, Latin Affairs is required to assist
OUR AMERICAN GENTLEMEN AND LADY CLIENTS IN THE RELATIONSHIP PROCESS BY ASKING FOR FULL DISCLOSURE AS FOLLOWS:
We are mandated to collect from the gentlemen client the following background information and also conduct an electronic search
on the National Sex Offender public registry and state public registry

This information and search result will be made available to any Ladies interested in meeting American men.
Please take a few minutes and complete the questionnaire below, sign, date and return to us with any purchases or tour payments.

By answering any question below marked "Yes," please provide us with detailed documentation. Send separate pages by mail if necessary.
Additional documents may require a translation fee.

Your Full Name:

Country of Residence:

State:

City:

Zip Code:

Phone:

Email Address:

Date of Birth - Month / Day / Year:

Any temporary or permanent civil protection order or restraining order issued against you?
If none, type no, else provide details below.

Any Federal, State, or local arrest or conviction for homicide, murder, manslaughter, assault, battery, domestic violence, rape, sexual assault, abusive sexual contact, sexual exploitation, incest, child abuse or neglect, torture, espionage, holding hostage, involuntary servitude, human trafficking, kidnapping, abduction, unlawful criminal restraint, false imprisonment, or stalking?
If none, type no, else provide details below.

Any Federal, State, or local arrest or conviction for-- (I) solely, principally, or incidentally engaging in prostitution; (II) a direct or indirect attempt to procure prostitutes or persons for the purpose of prostitution; or (III) receiving, in whole or in part, of the proceeds of prostitution.
If none, type no, else provide details below.

Any Federal, State, or local arrest or conviction for offenses related to controlled substances or alcohol.
If none, type no, else provide details below.

Your marital history, including whether you are single, currently married, whether you have been previously married and how many times, how your previous marriages were terminated and the date of termination, and whether you have previously sponsored an alien to whom you where engaged or married.
Please provide details below.

The ages if any of your children who are under the age of 18.
If none, type none, else provide details below.

All States and countries in which you have resided since you where 18 years of age
Please provide details below.

I CERTIFY AND ATTEST, under penalty of perjury and false statement, that my above CLIENT BACKGROUND INFORMATION IS TRUE AND COMPLETE. I also give my permission to LatinAffairs C por A to release and provide this information in any format to all interested foreign ladies available. 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 LATIN AFFAIRS C por A FROM ANY AND ALL LIABILITIES arising from my release of this information and any use of it.

Full Name

Today's Date (mm/dd/yyyy)