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ENTRY VISA FORM Participant I. Information about the person invited Family Name. First Name. Date of birth: Date................................... Month ...................... Year........................

I certify that at least one of the following: I do not reside in Cuba. I am a legal resident of the U.S. I am an alien, on a temporary visa, for 90 days or less, accompanying or following to join a family member who is a legal permanent resident of the U.S. (I hereby authorize the Federal Bureau of Investigation to verify my relationship to the immigrant family member and to collect the immigration and registration information of any subsequent U.S. citizen children born to either the immigrant family member and myself or to the immigrant family member and myself) II. Confirm that the person is not the immediate child of, married to, or residing with a Cuban spouse at the time of the participation, and that the person has a valid (valid on the visa) Cuban passport on the day of the survey. III. Identify the Cuban embassy or consulate from which he or she will receive assistance in the area survey. IV. Confirm whether the person is a member of the National Front: A1 and A2. If so, a brief description of the Party; The Cuban National Flag; The “Cuban Patriotic Front” flag; and/ or A3. If so, a brief description of the Communist Party. If not, the National Front and Communist Party. IV.7.5.2.2 I have previously been registered as an organizer of any activities outside Cuba which were organized in coordination with the Cuban Communist Party. However, I do not have authorization from the Cuban Government to conduct activities in coordination with the Cuban Communist Party outside of Cuba, and I am not directly affiliated with any organization in Cuba. A4 IV.7.8.1.1 I certify that I am not a Communist Party candidate. I will be responsible for my own voting and should make my voting as transparent as possible. A5 IV.7.8.2.2 I have the right to vote on this survey and that I have not participated in any activities in the past three years that I know of which were designed to circumvent the above voting restrictions. I will sign my name to every participant, but will not be present for voting. A6 IV.7.10 Acknowledgement of All Participants (Please provide a completed survey acknowledgement and signature sheet for each participant.) Confirmed Participants I. Information about Organization Name. Name of Organization, city, state, and country. 2. Name of Country. Country of birth, date in question. 3.

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