G-1579A Outstanding Americans by Choice Supplemental Questionnai

Outstanding Americans by Choice
Supplemental Questionnaire

USCIS
Form G-1579A

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

OMB No. 1615-NEW
Expires Pending

Please answer the following questions:

Part 1. Event Logistics
in-person recognition event on
?

Yes

No

2.

Are you willing to lead a group of new citizens in the Pledge of Allegiance if your recognition is presented
at a naturalization ceremony (not always applicable)?

Yes

No

3.

Do you consent to media interviews at one or more events?
If “Yes,” then please provide your organization's press office contact, if applicable.

Yes

No

4.

How would you like your name to appear on Outstanding Americans by Choice certificate?

5.

Please list any guest (up to 5) who will attend the ceremony with you. Include their name, title, organization and relation to you.

1.

Are you available to attend the
at

DRAFT
Not for
Production
02/08/2023

Guest Name (Last Name,
First Name)

in

Title (if applicable)

Organization (if applicable)

Relationship to You

Part 2. Optional Future Opportunities
Do you consent to USCIS to contact you in the future about potential volunteer opportunities to provide information to others about
immigration benefits including naturalization?
I consent
I do not consent

Form G-1579A 08/31/21

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