!NGO Referral Validation PRM v1.2

Referral Information Verification (v1.2)

Step 1 of 13

This field is hidden when viewing the form

Referral ID

Important Reminder

Access to the USRAP is free. Using a translator or preparer is not necessary as these services will be provided. Beware of any scams or potential exploitation by third parties. No one should pay any fees or complete favors to unauthorizedindividuals claiming to be able to assist or expedite resettlement to the United States or to gain access to the program. Do notshare your personal information with anyone whom you do not trust. Avoid emailing your identity documents to anyone; you should always maintain control over your identity documents. Please report fraud at: U.S. Refugee Admissions Program (USRAP) Tip Form

Consent(Required)

By proceeding with this form, I acknowledge and agree that Amerikaners operates solely in a supportive role and has no authority to approve, deny, influence, or comment on the outcome of any refugee application. Its role is strictly limited to collecting, preparing, and submitting information to the relevant United States authorities, and to its designated partners, for their exclusive consideration, review and adjudication.

I voluntarily consent to the use and secure transmission of my information for this purpose, including the sharing of my information with the U.S. Government and its authorised partners in the U.S. Refugee Admission Program (USRAP) process.

I confirm that all information I provide is true, accurate, and complete to the best of my knowledge.

I agree to the terms below

This field is hidden when viewing the form

Contact

This is a hidden field and is intended to be used for subsequent form sends (e.g. for a second send for validations) where they don't neccesssarily need to answer most of these questions again

Have you or your spouse received a Notice of Ineligibility letter from USCIS?(Required)

This means that you had previously been referred, had interviews and may have done medicals before. After this, you then received a notice rejecting you.

Yes

My Current Contact Status (Select all that apply)

This means what contact have you had in the PAST.

Nobody has phoned me yet

Emailed for MIE fingerprints

Called about my Persecution Claim

Busy with medicals and USCIS

Approved to Travel

Who called you, and when(Required)

Did you apply more than once?(Required)

Yes

Give details of possible duplicate applications please:(Required)

Write emails and principal applicants with notes.

Are you on anyone else's application as a dependent?(Required)

Only answer "Yes" if your spouse did a seperate/their own application and you are on theirs as a dependent.

Yes

Please provide name of the Principal Applicant(Required)

Do you still wish to proceed with your application(Required)

Yes

Please give a short reason for your withdrawal from USRAP at this time.(Required)

Remember you can activate your application again later by email to us.

Your application size of [Applicant_ReferralSize] includes the following people: [ApplicationNames]

Is this correct?

Yes

How many family members are missing?(Required)

Please note only legal spouse and biological/adopted children under 21 can be added.

Please enter a number from 1 to 7.

This field is hidden when viewing the form

Applicant_ReferralSize_Original

This field is hidden when viewing the form

Total Family Size(Required)

Why are you increasing your family size?

I forgot to add them to my application or newborn

They were on my application but are not listed

I/they applied on seperate applications

You will get the opportunity to add their details at the end of this form

Thanks for your explanation

You will get the opportunity to add their details at the end of this form. We will attempt to locate their cases from your details provided, and if possible, combine them into your application.

Do you wish to be the Primary Applicant for your family?(Required)

Yes

Principal Applicant

This field is hidden when viewing the form

Location

Interview Location: Please choose the city closest to you(Required)

Cape Town

Pretoria

Earliest Travel Date

Keep this Travel Date?(Required)

Yes

Corrected Earliest Travel Date(Required)

DD slash MM slash YYYY

First Name

First Name Correct?(Required)

Yes

Corrected: First Name(Required)

Middle Name(s)

Middle Name(s) Correct?(Required)

Yes

Corrected: Middle Name(s)(Required)

Surname

Surname Correct?(Required)

Yes

Corrected: Surname(Required)

Sex

Sex Correct?(Required)

Yes

Corrected: Sex(Required)

Male

Female

Date of Birth

Date of Birth Correct?(Required)

Yes

Corrected: Date of Birth(Required)

DD slash MM slash YYYY

Ethnicity

Ethnicity Correct?(Required)

Yes

Corrected: Ethnicity(Required)

Afrikaner

White English South African

Indian South African

Coloured South African

Other Ancestry

Nationality

Nationality Correct?(Required)

Yes

Corrected: Nationality(Required)

National ID Number

ID Number Correct?(Required)

Yes

Corrected: National ID Number(Required)

Dual Nationality

Dual Nationality means a citizen/national of another country?

Dual Nationality Correct?(Required)

Yes

Corrected: Dual Nationality(Required)

Yes

Marital Status

Marital Status Correct?(Required)

Yes

Corrected: Marital Status(Required)

Never Married

Married

Divorced

Widowed

Primary Email

Primary Email Correct?(Required)

Yes

Corrected: Email(Required)

Primary Phone

Primary Phone Correct?(Required)

Yes

Corrected: Primary Phone(Required)

DEPENDANT 1: (Accompanying Principal)

Dependant 1: First Name

1 First Name Correct?(Required)

Yes

Corrected: First Name(Required)

Dependant 1: Middle Name(s)

1 Middle Name(s) Correct?(Required)

Yes

Corrected: Middle Name(s)(Required)

Dependant 1: Surname

1 Surname Correct?(Required)

Yes

Corrected: Surname(Required)

Dependant 1: Sex

1 Sex Correct?(Required)

Yes

Corrected: Sex(Required)

Male

Female

Dependant 1: Date of Birth

1 Date of Birth Correct?(Required)

Yes

Corrected: Date of Birth(Required)

DD slash MM slash YYYY

Dependant 1: Ethnicity

1 Ethnicity Correct?(Required)

Yes

Corrected: Ethnicity(Required)

Afrikaner

White English South African

Indian South African

Coloured South African

Other Ancestry

Dependant 1: Nationality

1 Nationality Correct?(Required)

Yes

Corrected: Nationality(Required)

Dependant 1: National ID Number

1 ID Number Correct?(Required)

Yes

Corrected: National ID Number(Required)

Dependant 1: Dual Nationality

Dual Nationality means a citizen/national of another country?

1 Dual Nationality Correct?(Required)

Yes

Corrected: Dual Nationality(Required)

Yes

Dependant 1: Marital Status

1 Marital Status Correct?(Required)

Yes

Corrected: Marital Status(Required)

Never Married

Married

Divorced

Widowed

Dependant 1: Primary Email

1 Primary Email Correct?(Required)

Yes

Corrected: Email(Required)

Dependant 1: Primary Phone

1 Primary Phone Correct?(Required)

Yes

Corrected: Primary Phone(Required)

DEPENDANT 2: (Accompanying Principal)

Dependant 2: First Name

2 First Name Correct?(Required)

Yes

Corrected: First Name(Required)

Dependant 2: Middle Name(s)

2 Middle Name(s) Correct?(Required)

Yes

Corrected: Middle Name(s)(Required)

Dependant 2: Surname

2 Surname Correct?(Required)

Yes

Corrected: Surname(Required)

Dependant 2: Sex

2 Sex Correct?(Required)

Yes

Corrected: Sex(Required)

Male

Female

Dependant 2: Date of Birth

2 Date of Birth Correct?(Required)

Yes

Corrected: Date of Birth(Required)

DD slash MM slash YYYY

Dependant 2: Ethnicity

2 Ethnicity Correct?(Required)

Yes

Corrected: Ethnicity(Required)

Afrikaner

White English South African

Indian South African

Coloured South African

Other Ancestry

Dependant 2: Nationality

2 Nationality Correct?(Required)

Yes

Corrected: Nationality(Required)

Dependant 2: National ID Number

2 ID Number Correct?(Required)

Yes

Corrected: National ID Number(Required)

Dependant 2: Dual Nationality

Dual Nationality means a citizen/national of another country?

2 Dual Nationality Correct?(Required)

Yes

Corrected: Dual Nationality(Required)

Yes

Dependant 2: Marital Status

2 Marital Status Correct?(Required)

Yes

Corrected: Marital Status(Required)

Never Married

Married

Divorced

Widowed

Dependant 2: Primary Email

2 Primary Email Correct?(Required)

Yes

Corrected: Email(Required)

Dependant 2: Primary Phone

2 Primary Phone Correct?(Required)

Yes

Corrected: Primary Phone(Required)

DEPENDANT 3: (Accompanying Principal)

Dependant 3: First Name

3 First Name Correct?(Required)

Yes

Corrected: First Name(Required)

Dependant 3: Middle Name(s)

3 Middle Name(s) Correct?(Required)

Yes

Corrected: Middle Name(s)(Required)

Dependant 3: Surname

3 Surname Correct?(Required)

Yes

Corrected: Surname(Required)

Dependant 3: Sex

3 Sex Correct?(Required)

Yes

Corrected: Sex(Required)

Male

Female

Dependant 3: Date of Birth

3 Date of Birth Correct?(Required)

Yes

Corrected: Date of Birth(Required)

DD slash MM slash YYYY

Dependant 3: Ethnicity

3 Ethnicity Correct?(Required)

Yes

Corrected: Ethnicity(Required)

Afrikaner

White English South African

Indian South African

Coloured South African

Other Ancestry

Dependant 3: Nationality

3 Nationality Correct?(Required)

Yes

Corrected: Nationality(Required)

Dependant 3: National ID Number

3 ID Number Correct?(Required)

Yes

Corrected: National ID Number(Required)

Dependant 3: Dual Nationality

Dual Nationality means a citizen/national of another country?

3 Dual Nationality Correct?(Required)

Yes

Corrected: Dual Nationality(Required)

Yes

Dependant 3: Marital Status

3 Marital Status Correct?(Required)

Yes

Corrected: Marital Status(Required)

Never Married

Married

Divorced

Widowed

Dependant 3: Primary Email

3 Primary Email Correct?(Required)

Yes

Corrected: Email(Required)

Dependant 3: Primary Phone

3 Primary Phone Correct?(Required)

Yes

Corrected: Primary Phone(Required)

DEPENDANT 4: (Accompanying Principal)

Dependant 4: First Name

4 First Name Correct?(Required)

Yes

Corrected: First Name(Required)

Dependant 4: Middle Name(s)

4 Middle Name(s) Correct?(Required)

Yes

Corrected: Middle Name(s)(Required)

Dependant 4: Surname

4 Surname Correct?(Required)

Yes

Corrected: Surname(Required)

Dependant 4: Sex

4 Sex Correct?(Required)

Yes

Corrected: Sex(Required)

Male

Female

Dependant 4: Date of Birth

4 Date of Birth Correct?(Required)

Yes

Corrected: Date of Birth(Required)

DD slash MM slash YYYY

Dependant 4: Ethnicity

4 Ethnicity Correct?(Required)

Yes

Corrected: Ethnicity(Required)

Afrikaner

White English South African

Indian South African

Coloured South African

Other Ancestry

Dependant 4: Nationality

4 Nationality Correct?(Required)

Yes

Corrected: Nationality(Required)

Dependant 4: National ID Number

4 ID Number Correct?(Required)

Yes

Corrected: National ID Number(Required)

Dependant 4: Dual Nationality

Dual Nationality means a citizen/national of another country?

4 Dual Nationality Correct?(Required)

Yes

Corrected: Dual Nationality(Required)

Yes

Dependant 4: Marital Status

4 Marital Status Correct?(Required)

Yes

Corrected: Marital Status(Required)

Never Married

Married

Divorced

Widowed

Dependant 4: Primary Email

4 Primary Email Correct?(Required)

Yes

Corrected: Email(Required)

Dependant 4: Primary Phone

4 Primary Phone Correct?(Required)

Yes

Corrected: Primary Phone(Required)

DEPENDANT 5: (Accompanying Principal)

Dependant 5: First Name

5 First Name Correct?(Required)

Yes

Corrected: First Name(Required)

Dependant 5: Middle Name(s)

5 Middle Name(s) Correct?(Required)

Yes

Corrected: Middle Name(s)(Required)

Dependant 5: Surname

5 Surname Correct?(Required)

Yes

Corrected: Surname(Required)

Dependant 5: Sex

5 Sex Correct?(Required)

Yes

Corrected: Sex(Required)

Male

Female

Dependant 5: Date of Birth

5 Date of Birth Correct?(Required)

Yes

Corrected: Date of Birth(Required)

DD slash MM slash YYYY

Dependant 5 Ethnicity

5 Ethnicity Correct?(Required)

Yes

Corrected: Ethnicity(Required)

Afrikaner

White English South African

Indian South African

Coloured South African

Other Ancestry

Dependant 5: Nationality

5 Nationality Correct?(Required)

Yes

Corrected: Nationality(Required)

Dependant 5: National ID Number

5 ID Number Correct?(Required)

Yes

Corrected: National ID Number(Required)

Dependant 5: Dual Nationality

Dual Nationality means a citizen/national of another country?

5 Dual Nationality Correct?(Required)

Yes

Corrected: Dual Nationality(Required)

Yes

Dependant 5: Marital Status

5 Marital Status Correct?(Required)

Yes

Corrected: Marital Status(Required)

Never Married

Married

Divorced

Widowed

Dependant 5: Primary Email

5 Primary Email Correct?(Required)

Yes

Corrected: Email(Required)

Dependant 5: Primary Phone

5 Primary Phone Correct?(Required)

Yes

Corrected: Primary Phone(Required)

DEPENDANT 6: (Accompanying Principal)

Dependant 6: First Name

6 First Name Correct?(Required)

Yes

Corrected: First Name(Required)

Dependant 6: Middle Name(s)

6 Middle Name(s) Correct?(Required)

Yes

Corrected: Middle Name(s)(Required)

Dependant 6: Surname

6 Surname Correct?(Required)

Yes

Corrected: Surname(Required)

Dependant 6: Sex

6 Sex Correct?(Required)

Yes

Corrected: Sex(Required)

Male

Female

Dependant 6: Date of Birth

6 Date of Birth Correct?(Required)

Yes

Corrected: Date of Birth(Required)

DD slash MM slash YYYY

Dependant 6: Ethnicity

6 Ethnicity Correct?(Required)

Yes

Corrected: Ethnicity(Required)

Afrikaner

White English South African

Indian South African

Coloured South African

Other Ancestry

Dependant 6: Nationality

6 Nationality Correct?(Required)

Yes

Corrected: Nationality(Required)

Dependant 6: National ID Number

6 ID Number Correct?(Required)

Yes

Corrected: National ID Number(Required)

Dependant 6: Dual Nationality

Dual Nationality means a citizen/national of another country?

6 Dual Nationality Correct?(Required)

Yes

Corrected: Dual Nationality(Required)

Yes

Dependant 6: Marital Status

6 Marital Status Correct?(Required)

Yes

Corrected: Marital Status(Required)

Never Married

Married

Divorced

Widowed

Dependant 6: Primary Email

6 Primary Email Correct?(Required)

Yes

Corrected: Email(Required)

Dependant 6: Primary Phone

6 Primary Phone Correct?(Required)

Yes

Corrected: Primary Phone(Required)

DEPENDANT 7: (Accompanying Principal)

Dependant 7: First Name

7 First Name Correct?(Required)

Yes

Corrected: First Name(Required)

Dependant 7: Middle Name(s)

7 Middle Name(s) Correct?(Required)

Yes

Corrected: Middle Name(s)(Required)

Dependant 7: Surname

7 Surname Correct?(Required)

Yes

Corrected: Surname(Required)

Dependant 7: Sex

7 Sex Correct?(Required)

Yes

Corrected: Sex(Required)

Male

Female

Dependant 7: Date of Birth

7 Date of Birth Correct?(Required)

Yes

Corrected: Date of Birth(Required)

DD slash MM slash YYYY

Dependant 7: Ethnicity

7 Ethnicity Correct?(Required)

Yes

Corrected: Ethnicity(Required)

Afrikaner

White English South African

Indian South African

Coloured South African

Other Ancestry

Dependant 7: Nationality

7 Nationality Correct?(Required)

Yes

Corrected: Nationality(Required)

Dependant 7: National ID Number

7 ID Number Correct?(Required)

Yes

Corrected: National ID Number(Required)

Dependant 7: Dual Nationality

Dual Nationality means a citizen/national of another country?

7 Dual Nationality Correct?(Required)

Yes

Corrected: Dual Nationality(Required)

Yes

Dependant 7: Marital Status

7 Marital Status Correct?(Required)

Yes

Corrected: Marital Status(Required)

Never Married

Married

Divorced

Widowed

Dependant 7: Primary Email

7 Primary Email Correct?(Required)

Yes

Corrected: Email(Required)

Dependant 7: Primary Phone

7 Primary Phone Correct?(Required)

Yes

Corrected: Primary Phone(Required)

FORGOT YOUR DEPENDENTS?

You said you are married. Is your spouse travelling with you?(Required)

Yes

You said you are married. Is your spouse travelling with you?(Required)

Yes

Do you have any other dependents (under 21) living with you that should be on this application?(Required)

Yes

Please list your dependents and their relationship to you:(Required)

(Allowed dependents are a LEGAL SPOUSE or CHILDREN under 21)

Thank you! Please read the reminder and consent below, then Submit.

Important Reminder

Consent(Required)

By clicking SUBMIT:

I can read and understand English, and have read and understand every question and instruction on this form, as well as my answer to every question.

I confirm that all the information I have provided in this form is true, accurate, and complete to the best of my knowledge.

I understand that the information I provide will be reviewed by the relevant United States authorities, and its designated partners.

I acknowledge that Amerikaners operates only in a supportive role in the U.S. Refugee Admissions Program (USRAP) and has no authority to influence, approve, deny, or guarantee the outcome of any application.

I consent to my information being securely shared with the U.S. Government and its autorised partners.

I authorise Amerikaners, the relevant United States authorities, and their authorised partners to contact me by phone, WhatsApp and/or email.

I agree to the terms below:

This field is hidden when viewing the form

DepAge1

This field is hidden when viewing the form

DepAge2

This field is hidden when viewing the form

DepAge3

This field is hidden when viewing the form

DepAge4

This field is hidden when viewing the form

DepAge5

This field is hidden when viewing the form

DepAge6

This field is hidden when viewing the form

DepAge7

We’re here for you!

First Name(Required)

Surname(Required)

Email(Required)

Phone(Required)

Choose your Location(Required)

South Africa

United States of America

Thanks for reaching out. This contact form is for general questions only. If you have a specific question about your refugee application status, please note that we cannot assist at Amerikaners. Either you need to wait for contact after applying or, if you have a case file already, check your dashboard.

Which State(Required)

Which City(Required)

Agency Name(Required)

For urgent support, we will make contact with you in 3 business hours of submission – time zone adjusted for SA. We do have the ability to escalate the matter in Washington if needed, so thank you for reaching out and please stand by for next contact.

Message(Required)