G-1580 Citizenship Ambassadors Nominee Questionnaire

Citizenship Ambassador, Nominee Questionnaire
Department of Homeland Security
U.S. Citizenship and Immigration Services

USCIS
Form G-1580
OMB No. 1615-NEW
Expires Pending

Part 1. Program Requirements
1.

I am a U.S. citizen by (check one):
Birth in the United States

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Birth abroad to U.S. citizen parent(s)

Acquisition of citizenship after birth through naturalization of parent(s)
Naturalization
2.

I am providing a scanned copy of one of the following as proof of citizenship (check one):
Certificate of Citizenship;
U.S. passport;

U.S. birth certificate;

Naturalization certificate; or

Consular report of birth abroad (CRBA)
3.

If you cannot provide your Naturalization Certificate or Certificate of Citizenship, do you consent to
USCIS confirming your status as a U.S. citizen? (Skip if you provided evidence as documented in
question 3).

4.

If you answered yes to the previous question, provide as much of the following information you can to allow us to locate your
information in our internal databases to confirm your status as U.S. citizen.
Naturalization Date
(mm/dd/yyyy)

Yes

No

Alien Registration Number (A-Number)
► A-

Country of nationality (country of birth and/or country of last habitual residence):

Part 2. Information About Nominee
USCIS may contact you to obtain additional information or to provide notifications during the nominee selection process.
1.

Nominee's Full Name
Family Name (Last Name)

Given Name (First Name)

Middle Name (if applicable)

Date of Birth
(mm/dd/yyyy)

Form G-1580 PENDING

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Part 2. Information About Nominee (continued)
2.

Nominee's Address(es)
A. Current Physical Address
In Care Of Name (if any)

Street Number and Name

City or Town

Province

Apt. Ste. Flr. Number

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State

Postal Code

ZIP Code

Country

B. Work Address (if applicable)
In Care Of Name (if any)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

3.

Phone Number

Primary Mobile Number

4.

Postal Code

ZIP Code

Country

Alternate Phone Number (if applicable)

Email Address (if any)

NOTE: If you have an assistant with whom we should correspond on your behalf you may provide their name and contact
information. You will also need to add your signature below to grant USCIS authority to share your information with the individual
that you designate.
Assistant Contact information:
Primary Mobile Number:

Alternate:

Email Address:

By my signature, I consent to USCIS communicating with, and releasing records (or information) about me to the above-named
individual.
1.

Nominee's Signature

Form G-1580 PENDING

Date of Signature (mm/dd/yyyy)

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Part 3. Consent For Participation
I hereby consent to both serving and being publicly recognized as a USCIS Citizenship Ambassador pending verification of my status
as a U.S. citizen and my signing the Gratuitous Services Agreement. I understand that by consenting to public recognition as a
Citizenship Ambassador I may be identified as such during public events that are open to the press. I also understand that consenting
to such public recognition may result in media interest in my private life, immigration history, and work in the United States and my
prior country of residence.
1.

Nominee's Signature

Date of Signature (mm/dd/yyyy)

DRAFT
Not for
Production
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Form G-1580 PENDING

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