I Love Latins IMBRA Compliance Form




Print, Complete and Mail in IMBRA and Harmless Form
with your completed Romance tour reservations!

SPECIAL NOTE: Under new federal legislation effective March 07, 2006, I LOVE LATINS, is required to assist
OUR GENTLEMAN AND LADY CLIENTS IN THE RELATIONSHIP PROCESS  BY ASKING FOR FULL DISCLOSURE AS FOLLOWS:
We are mandated to collect from the gentlemen client the following background information and also conduct an electronic search
on the National Sex Offender public registry and state public registry. This information and search result will be made available to any Ladies
interested in meeting American men. Please complete the questionnaire below and sign and date, and return it to us.
I Love Latins has and will Always follow the law and would simply warn you upfront about doing business with Any agency that does not.

 If you answer “YES” to any of the questions below, please provide us with more detailed information and any applicable documents.
Please use additional pages if necessary.

 CLIENT BACKGROUND INFORMATION UNDER

INTERNATIONAL MARRIAGE BROKER REGULATION ACT OF 2005

FULL NAME: _______________________________________________________________

ADDRESS: _________________________________________________________________

CITY, STATE, ZIP:___________________________________________________________

TELEPHONE: _______________________________________________________________

CELL:______________________________________________________________________

E-MAIL ADDRESS: __________________________________________________________

DATE OF BIRTH: ____________________________________________________________

DO YOU HAVE:

(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:_______________

PAGE TWO (2)

(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, and whether the client has previously sponsored
an alien to whom the client was engaged or married.

NO:________________

YES:_______________

(vi) The ages of any of the United States client's children who are under the age of 18.

NO:________________

YES:_______________

(vii) All States and countries in which the United States client has resided since the client was 18 years of age.

NO:________________

YES:_______________

I _________________________, CERTIFY AND ATTEST, under penalty of perjury and false statement, that my above client background information is true and complete.
I also give my permission to I LOVE LATINS to release and provide this information in any format to all interested foreign ladies available.
I have provided any 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 I LOVE LATINS
FROM ANY AND ALL LIABILITIES arising from my release of this information and any use of it.

___________________________________________ Signature           _____/______/______ Date

COPYRIGHT © Date Single Latin Women and I LOVE LATINS.

Mail to:
Sam and Consuelo Smith
11517 Sabo Rd
Houston, Texas 77089 USA
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