G-1579 Outstanding Americans by Choice Nominee Questionnaire

Outstanding Americans by Choice,
Nominee Questionnaire

USCIS
Form G-1579

Department of Homeland Security
U.S. Citizenship and Immigration Services

OMB No. 1615-NEW
Expires Pending

Part 1. Program Requirements
1.

Are you a naturalized U.S. citizen?

2.

Can you provide a copy of your Certificate of Naturalization?

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Production
02/08/2023

Yes

No

Yes

No

Yes

No

If “Yes,” then please provide a scanned copy of your certificate.
3.

If you are unable to provide your naturalization certificate, do you consent to U.S. Citizenship and
Immigration Services (USCIS) using our internal databases to confirm your status as a naturalized U.S.
citizen?

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 naturalization status.
Naturalization Date (if any)
(mm/dd/yyyy)

Alien Registration Number (A-Number) (if any)
► A-

Date of Birth
(mm/dd/yyyy)

Country of Nationality (country of birth
and/or country of last habitual residence)
5.

Are you willing to provide 3-5 minutes of remarks or have someone deliver your remarks on your
behalf during one or more events promoting naturalization?

Yes

No

These remarks should be inspirational in nature and should focus on your personal journey and what U.S. citizenship means to
you. Please also share information about your own personal achievements and contributions to the United States. All speakers
must adhere to USCIS' Speakers Guidance found in the USCIS Policy Manual at
www.uscis.gov/policy-manual/volume-12-part-j-chapter-5.
6.

USCIS may use your photo, video, voice recording, remarks given during the recognition event on our
website or on other social media without restrictions.

Yes

No

A. You acknowledge that you will not receive any compensation for the use of these items.

Yes

No

7.

You are willing to provide a biography noting your achievements and a photo for USCIS to use in
perpetuity.

Yes

No

8.

You are willing to review content (web biography and USCIS remarks) about your background for
public release.

Yes

No

Part 2. Information About Nominee
1.

Nominee's Full Name
Family Name (Last Name)

Form G-1579 Pending

Given Name (First Name)

Middle Name (if applicable)

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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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Production
02/08/2023
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)

USCIS may contact you to obtain additional information or to provide notifications during the selection process.

Part 3. Consent For Participation
I hereby consent to being publicly recognized as an Outstanding Americans by Choice recipient pending verification of my status and
confirmation of eligibility. I also understand that the Outstanding Americans by Choice initiative is a public recognition which may
result in media interest in my private life, immigration history, and work and in the United States and my prior country of residence.
1.

Nominee's Signature

Form G-1579 Pending

Date of Signature (mm/dd/yyyy)

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