Irish Citizenship Consulting Services

Client Application

Personal Details |

Full Legal Name: Barbara Ann Burgess Email Address:bbburgess@comcast.net

Address: 8245 Geary Blvd Telephone: 415 668 7655
San Francisco, California USA 94121 Fax: Your Fax Number
Date of Birth: 11-Mar-54 Place of Birth: Niagara Falls, New York

Citizenship Services |

Please indicate the Service you require (tick √):

Irish Citizenship & Passport Application: Clients born in Ireland or with an Irish-born parent.
x Irish Derivative Citizenship Claim: Clients with an Irish-born grandparent.
Irish Citizenship by Marriage: Post Nuptial Declarations.
Irish Visa Consulting: Clients who wish to work/retire/live in Ireland.

Please indicate your preferred method of payment (tick √):

x Credit Card (Visa or MasterCard):

x By Fax By Phone By PayPal Online Form
Check by Fax [US Residents only]
PayPal: for payments by Credit Card or eCheck (your Bank Account)
MoneyBookers: for international payments by email [regulated by UK Government]

Please ensure that you have reviewed the current Schedule of Professional Fees.

Family Tree |

For joint “Family Applications” only

Please list the co-applicants, including dates and places of birth:

Please list the co-applicants, including birthdates.

Your Mother’s:

“DualCitizen.net” is a Service Mark of BNA Informatics, LLC

©2005 All Rights Reserved
Your Father’s:
Full Name: Mary Esther Burgess
Full Name: James Frederick Burgess Date of Birth: March 28, 1921
Date of Birth: February 12, 1920 Place of Birth:Niagara Falls New York
Place of Birth:Pleasant Garden, North Carolina
Year & Place of Passing (if applicable):
Year & Place of Passing (if applicable): N/A
1992 Alexandria Virginia

Year & Place of Your Parent’s Marriage:

1947 Niagara Falls New York
(If possible, please list the date, denomination, and church.)

Your Irish-born Grandparent (upon whom we should base your case)

Full Name at Birth:Edward Joseph Cuffe Date of Birth: Sept 27, 1894
Place of Birth: Claremorris,Ireland Religious Affiliation: Catholic
Year & Place of Passing (if applicable):
Niagara Falls New York

The spouse of your Irish-born Grandparent

Full Name at Birth: Mary Jane McCormack Date of Birth:

Place of Birth: Limerick Ireland Religious Affiliation:Catholic
Year & Place of Passing (if applicable):
Niagara Falls New York

Your Educational & Career Information: (for Work Permit & Business Visas only)

Confirmation |

“I confirm that I have read and understood the Schedule of Professional Fees and the Terms & Conditions
and that the information given in this application is accurate. I understand that DualCitizen.net offers a
grace period of three days starting on the date of my signing this application. If I have not cancelled this
application before the close of business on the third day, this application is deemed to be a Contract of
Engagement.”

E-SIGNATURE THROUGH WEB ACCOUNT Your Legal Name 1-Nov-05

Signature Printed Name and Date of Signing

“DualCitizen.net” is a Service Mark of BNA Informatics, LLC

©2005 All Rights Reserved