1. Passport Number

    2. Place of Issuance: City, Country, State/Province

    3. Issuing Country

    4. Issuance Date

    5. Expiration Date

    6. Surnames (As in Passport)

    7. First and Middle Names (As in Passport)

    8. Other Surnames Used (Maiden, Religious, Professional, Aliases)

    9. Other First and Middle Names Used

    10. Date of Birth

    11. Place of birth: City, Country, State/Province

    12. Nationality

    13. Sex

    14. National Identification Number (If applicable)

    15. Home Address (Include apartment number, street, city, state or province, postal zone and country)

    16. Phone Number

    17. Marital Status

    18. Spouse’s Full Name (Even if divorced or separated. Include maiden name)

    19. Spouse’s Date of Birth

    20. Name and Address of Present Employer or School

    21. Present Occupation (If retired, write “retired”. If student, write “student”.)

    22. When Do You Intend To Arrive In The U.S.? (Provide specific date if known)

    23. Email Address

    24. At What Address Will You Stay in The U.S.?

    25. Name and Telephone Numbers of Person in U.S. Who You Will Be Staying With or Visiting for Tourism or Business

    26. How Long Do You Intend To Stay In The U.S.?

    27. What is The Purpose of Your Trip?

    28. Who Will Pay For Your Trip?

    29. Have You Ever Been in The U.S.?

    30. Have You Ever Been Issued a U.S. Visa?

    31. Have You Ever Been Refused a U.S. Visa?

    32. Do You Intend To Work In The U.S.?

    33. Do You Intend To Study In The U.S.?

    34. Names and Relationships of Persons Traveling With You

    35. Has Your U.S. Visa Was Ever Been Cancelled or Revoked?

    36. Has Anyone Ever Filed an Immigrant Visa Petition on Your Behalf?

    37. Are Any of The Following Persons in The U.S., or Do They Have U.S. Legal Permanent Residence or U.S. Citizenship?

    Make YES or NO and indicate that person’s status in the U.S. (i.e., U.S. legal permanent resident, U.S. citizen, visiting, studying, woking, etc.)

    Husband/Wife

    Father/Mother

    Fiance/Fiancee

    Son/Daughter

    Brother/Sister

    38. IMPORTANT: ALL APPLICANTS MUST READ AND CHECK THE APPROPRIATE BOX FOR EACH ITEM.
    A visa may not be issued to persons who are within specific categories defined by law as inadmissible to the United States (exept when a waiver is obtained in advance). Is any of the following applicable to you?

    38.1 Have you ever been arrested or convicted for any offense or crime, even though subject of a pardon, amnesty or other similar legal action? Have you ever unlawfully distributed or sold a controlled substance (drug), or been a prostitute or procurer for prostitutes?

    38.2 Have you ever been refused admission to the U.S., or been the subject of a deportation hearing, or sought to obtain or assist others to obtain a visa, entry into the U.S., or any other U.S. immigration benefit by fraud or willful misrepresentation or other unlawful means? Have you attended a U.S. public elementary school on student (F) status or a public secondary school after November 30, 1996 without reimbursing the school?

    38.3 Do you seek to enter the United States to engage in export control violations, subversive or terrorist activities, or any other unlawful purpose? Are you a member or representative of a terrorist organization as currently designated by the U.S. Secretary of State? Have you ever participated in persecutions directed by the Nazi goverment of Germany: or have you ever participated in genocide?

    38.4 Have you ever violated the terms of a U.S. visa, or been unlawfully present in, or deported from, the United States?

    38.5 Have you ever withheld custody of a U.S. citizen child outside the United States from a person granted legal custody by a U.S. court, voted in the United States in violation of any law or regulation, or renounced U.S. citizenship for the purpose of avoiding taxation?

    38.6 Have you ever been afflicted aith a communicable disease of public health significance or a dangerous physical or mental disorder, or even been a drug abuser or addict?

    *While a YES answers does not automatically signify inlegibility for a visa, if you answered YES you may be required to personally appear before a consular officer.

    39. Was This Application Prepared by Another Person on Your Behalf? (If answer is YES, then have that person complete item 40)

    40. Application Prepared By:

    Signature of Person Preparing Form

    41. I certify that i have read and understood all the questions set forth in this application and the answers i have furnished on this form are true and correct to the best of my knowledge and belief. I understand that any false or misleading statement may result in the permanent refusal of a visa or denial of entry into the United States. I understand that possession of a visa does not automatically entitle the bearer to enter the United States of America upon arrival at a port of entry if he or she is found inadmissible.