International Marriage Broker Regulation Act of 2005

Client Background Information

SPECIAL NOTE: Under federal legislation TLC Worldwide is mandated to collect the following background information from each gentleman who wishes to use our service. We will also be required to conduct an electronic search on the National Sex Offender public registry and state public registry (http://www.nsopr.gov/). This information and search results will then be translated into Spanish and made available to all ladies interested in meeting American men. Please complete, sign & date the questionnaire below and return it to us. This takes just a few minutes.

If you answer “YES” to any of the questions below, please provide a Detailed Statement of Explanation and Information, or alternatively any Necessary Optional Documentation. Additional documents may require a translation fee.

No	Yes	(i) Any temporary or permanent civil protection order or restraining order issued against the United States client.
No	Yes	(ii) Any Federal, State, or local arrest or conviction of the United States client for homicide, murder, manslaughter, assault, battery, domestic violence, rape, sexual assault, abusive sexual contact, sexual exploitation, incest, child abuse or neglect, torture, trafficking, peonage, holding hostage, involuntary servitude, slave trade, kidnapping, abduction, unlawful criminal restraint, false imprisonment, or stalking.
No	Yes	(iii) Any Federal, State, or local arrest or conviction of the United States client 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.
No	Yes	(iv) Any Federal, State, or local arrest or conviction of the United States client for offenses related to controlled substances or alcohol.
No	Yes	(v) Marital history of the United States client, including whether the client is currently married, whether the client has previously been married and how many times, how previous marriages of the client were terminated and the date of termination. ( Month / Day / Year).
No	Yes	Has the client has previously sponsored an alien to whom the client was engaged or married. If so, list details.
No	Yes	(vi) The ages of any of the United States client's children who are under the age of 18.
	Yes	(vii) REQUIRED: List all States and countries in which the United States client has resided since the client was 18 years of age.

I Certify and Attest, that my above Client Background Information Is True and Complete. I also give my permission to TLC Worldwide to release and provide this information in any format to all interested foreign ladies available. I have provided all 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 TLC WORLDWIDE from any and all liabilities arising from my release of this information and any use of it.

Signature (required):
Date (required):
Email Address (required):
Date of Birth (required):
Address (required):
City (required):
State or Province (required):
ZIP or Postal Code (required):
Country (required):

Also Needed for Tours - Application for Reserved Space !

Mail to: TLC Worldwide, P.O.Box 924994, Houston, TX 77292-4994, or
Fax: (713) 681-0950 or E-mail: tlcworld@nol.net this form and all supporting documentation.

For Internal Use Only, (Client does not complete) Date _____/______/______
Search By:______________________________ Result:___________________________________
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