16/5/2016

ConsularElectronicApplicationCenterPrintApplication

OnlineNonimmigrantVisaApplication(DS160)
ApplicationSensitiveButUnclassified(SBU)
Wedonotneedaprintedcopyofyourapplicationatanypointduringyourinterviewprocess.Onlyprintthis
applicationifyouwantacopyforyourownrecords.Ifyouprintyourapplication,pleasekeepitsecure.
PhotoProvided:

ConfirmationNumber:

YourPersonalCopyDoNotBringtoInterview
Personal,Address,Phone,andPassport/TravelDocumentInformation
NameProvided:

CASTILLOCOLIN,BERNARDITA

FullNameinNativeLanguage:

DOESNOTAPPLY

OtherNamesUsed:

NO

TelecodeNameUsed:

NO

Sex:

FEMALE

MaritalStatus:

WIDOWED

DateofBirth:

16APRIL1958

PlaceofBirth:

AMANALCO,MEXICO,MEXICOSTATEOFMEXICO

Country/RegionofOrigin(Nationality):

MEXICO

Doyouholdorhaveyouheldanynationalityotherthantheone
indicatedaboveonnationality?

NO

Areyouapermanentresidentofacountry/regionotherthanyour
country/regionoforigin(nationality)above?

NO

NationalIdentificationNumber:

0157017371928

U.S.SocialSecurityNumber:

113987601

U.S.TaxpayerIDNumber:

DOESNOTAPPLY

HomeAddress:

ELPOTREROSINNUMERO

City:

AMANALCO

State/Province:

MEXICO

https://ceac.state.gov/GenNIV/common/printapplication.aspx?BAZbOcZOo5SXGBRZN7IvdkN0a4PRtZCqaO%2f1sBrEC6g%3d

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ConsularElectronicApplicationCenterPrintApplication

PostalZone/ZIPCode:

51260

Country/Region:

MEXICO

SameMailingAddress?

YES

PrimaryPhoneNumber:

5544633250

SecondaryPhoneNumber:

7224757157

WorkPhoneNumber:

DOESNOTAPPLY

EmailAddress:

[email protected]

Passport/TravelDocumentType:

REGULAR

Passport/TravelDocumentNumber:

G20621972

PassportBookNumber:

G20621972

Country/AuthoritythatIssuedPassport/TravelDocument:

MEXICO

CityWhereIssued:

TOLUCA

State/ProvinceWhereIssued:

MEXICO

Country/RegionWhereIssued:

MEXICO

IssuanceDate:

12MAY2016

ExpirationDate:

12MAY2022

Haveyoueverlostapassportorhadonestolen?

NO

TravelInformation
TheListofPurposesofTriptotheU.S.
PurposeofTriptotheU.S.(1):

TEMP.BUSINESSPLEASUREVISITOR(B)

Specify:

BUSINESS&TOURISM(TEMPORARYVISITOR)
(B1/B2)

IntendedDateofArrival:

05AUGUST2016

IntendedLengthofStayinU.S.:

2WEEK(S)

AddresswhereyouwillstayintheU.S.:

50LOGDALEST

City,State,Postal/ZipCode:

STATENISLAND,NEWYORK10314

Person/EntityPayingforYourTrip:

OTHERPERSON

PersonPayingforYourTrip:

REYES,ADRIANA

TelephoneNumber:

3472154148

EmailAddress:

DOESNOTAPPLY

RelationshiptoYou:

OTHERRELATIVE

Istheaddressofthepartypayingforyourtripthesameasyour
HomeorMailingAddress?

YES

Arethereotherpersonstravelingwithyou?

YES

Areyoutravelingaspartofagroupororganization?

NO

PersonsTravelingwithYou:
Name(1):

QUINTEROALVAREZ,PETRA

RelationshiptoYou:

OTHERRELATIVE

HaveyoueverbeenintheU.S.?

NO

HaveyoueverbeenissuedaU.S.visa?

NO

HaveyoueverbeenrefusedaU.S.Visa,orbeenrefusedadmission
totheUnitedStates,orwithdrawnyourapplicationforadmissionat
theportofentry?

NO

Hasanyoneeverfiledanimmigrantpetitiononyourbehalfwiththe
UnitedStatesCitizenshipandImmigrationServices?

NO

https://ceac.state.gov/GenNIV/common/printapplication.aspx?BAZbOcZOo5SXGBRZN7IvdkN0a4PRtZCqaO%2f1sBrEC6g%3d

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U.S.ContactInformation
ContactPersonNameintheU.S.:

REYES,ADRIANA

OrganizationNameintheU.S.:

DONOTKNOW

RelationshiptoYou:

OTHER

U.S.ContactAddress:

50LOGDALEST
STATENISLAND,NEWYORK10314

PhoneNumber:

3472154148

EmailAddress:

DOESNOTAPPLY

FamilyInformation
Father'sSurnames:

CASTILLOLEON

Father'sGivenNames:

AGUSTIN

Father'sDateofBirth:

28AUGUST1933

IsyourfatherintheU.S.?

NO

Mother'sSurnames:

COLINVILCHIS

Mother'sGivenNames:

ANGELINA

Mother'sDateofBirth:

10AUGUST1933

IsyourmotherintheU.S.?

NO

Doyouhaveanyimmediaterelatives,notincludingparentsinthe
U.S.?

NO

DoyouhaveanyotherrelativesintheUnitedStates?

NO

DeceasedSpouse'sFullName:

AVILAVELAZQUEZ,NAVOR

DeceasedSpouse'sDateofBirth:

12JUNE1949

DeceasedSpouse'sCountry/RegionofOrigin(Nationality):

MEXICO

DeceasedSpouse'sCityofBirth:

POTRERO

Country/RegionofBirth:

MEXICOSTATEOFMEXICO

Work/Education/TrainingInformation
PrimaryOccupation:

AGRICULTURE

PresentEmployerorSchoolName:

BERNARDITACASILLOCOLIN

Address:

ELPOTREROSINNUMERO

City:

AMANALCO

State/Province:

MEXICO

PostalZone/ZipCode:

51260

Country/Region:

MEXICO

WorkPhoneNumber:

7224757157

MonthlySalaryinLocalCurrency(ifemployed):

28000

BrieflyDescribeyourDuties:

SIEMBRADEMAIZYGANADOVACUNO

SecurityandBackgroundInformation
Doyouhaveacommunicablediseaseofpublichealthsignificance?(Communicablediseasesofpublic
significanceincludechancroid,gonorrhea,granulomainguinale,infectiousleprosy,lymphogranuloma
venereum,infectiousstagesyphilis,activetuberculosis,andothersdiseasesasdeterminedbytheDepartment
ofHealthandHumanServices.)

NO

Doyouhaveamentalorphysicaldisorderthatposesorislikelytoposeathreattothesafetyorwelfareof
yourselforothers?

NO

Areyouorhaveyoueverbeenadrugabuseroraddict?

NO

Haveyoueverbeenarrestedorconvictedforanyoffenseorcrime,eventhoughsubjectofapardon,amnesty,
orothersimilaraction?

NO

https://ceac.state.gov/GenNIV/common/printapplication.aspx?BAZbOcZOo5SXGBRZN7IvdkN0a4PRtZCqaO%2f1sBrEC6g%3d

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Haveyoueverviolated,orengagedinaconspiracytoviolate,anylawrelatingtocontrolledsubstances?

NO

AreyoucomingtotheUnitedStatestoengageinprostitutionorunlawfulcommercializedviceorhaveyou
beenengagedinprostitutionorprocuringprostituteswithinthepast10years?

NO

Haveyoueverbeeninvolvedin,ordoyouseektoengagein,moneylaundering?

NO

HaveyouevercommittedorconspiredtocommitahumantraffickingoffenseintheUnitedStatesoroutside
theUnitedStates?

NO

Areyouthespouse,son,ordaughterofanindividualwhohascommittedorconspiredtocommitahuman
traffickingoffenseintheUnitedStatesoroutsidetheUnitedStatesandhaveyouwithinthelastfiveyears,
knowinglybenefitedfromthetraffickingactivities?

NO

Haveyouknowinglyaided,abetted,assistedorcolludedwithanindividualwhohascommittedorconspiredto
commitaseverehumantraffickingoffenseintheUnitedStatesoroutsidetheUnitedStates?

NO

Doyouseektoengageinespionage,sabotage,exportcontrolviolations,oranyotherillegalactivitywhilein
theUnitedStates?

NO

DoyouseektoengageinterroristactivitieswhileintheUnitedStatesorhaveyoueverengagedinterrorist
activities?

NO

Haveyoueverordoyouintendtoprovidefinancialassistanceorothersupporttoterroristsorterrorist
organizations?

NO

Areyouamemberorrepresentativeofaterroristorganization?

NO

Haveyoueverordered,incited,committed,assisted,orotherwiseparticipatedingenocide?

NO

Haveyouevercommitted,ordered,incited,assisted,orotherwiseparticipatedintorture?

NO

Haveyoucommitted,ordered,incited,assisted,orotherwiseparticipatedinextrajudicialkillings,political
killings,orotheractsofviolence?

NO

Haveyoueverengagedintherecruitmentortheuseofthechildsoldiers?

NO

Haveyou,whileservingasagovernmentofficial,beenresponsibleforordirectlycarriedout,atanytime,
particularlysevereviolationsofreligiousfreedom?

NO

Haveyoueverbeendirectlyinvolvedintheestablishmentorenforcementofthepopulationcontrolsforcinga
womantoundergoanabortionagainstherfreechoiceoramanorawomantoundergosterilizationagainsthis
orherfreewill?

NO

Haveyoueverbeendirectlyinvolvedinthecoercivetransplantationofhumanorgansorbodilytissue?

NO

Haveyoueversoughttoobtainorassistotherstoobtainavisa,entryintotheUnitedStates,oranyother
UnitedStatesimmigrationbenefitbyfraudorwillfulmisrepresentationorotherunlawfulmeans?

NO

HaveyoueverwithheldcustodyofaU.S.citizenchildoutsidetheUnitedStatesfromapersongrantedlegal
custodybyaU.S.court?

NO

HaveyouvotedintheUnitedStatesinviolationofanylaworregulation?

NO

HaveyoueverrenouncedUnitedStatescitizenshipforthepurposeofavoidingtaxation?

NO

LocationInformation
Locationwhereyouwillbesubmittingyourapplication
CurrentLocation:

MEXICOCITY,MEXICO

PreparerofApplication
Didanyoneassistyouinfillingoutthisapplication?

YES

PreparerSurnames:

PALOMINOCAMACHO

PreparerGivenNames:

EMMANUEL

OrganizationName:

DOESNOTAPPLY

StreetAddress:

CALTLYLT7MZ365
PLATEROS

City:

CHIMALHUACAN

State/Province:

ESTADODEMEXICO

PostalZone/ZIPCode:

56356

Country/Region:

MEXICO

https://ceac.state.gov/GenNIV/common/printapplication.aspx?BAZbOcZOo5SXGBRZN7IvdkN0a4PRtZCqaO%2f1sBrEC6g%3d

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RelationshiptoYou:

FRIEND

YourPersonalCopyDoNotBringtoInterview
Youelectronicallysignedyourapplicationon16May201601:18:48(GMT05:00).Youwererequiredtoelectronicallysignyour
applicationyourself,unlessotherwiseexemptbyregulation,eveniftheapplicationwaspreparedbysomeoneotherthan
yourself.Yourelectronicsignaturecertifiesthatyouhavereadandunderstoodthequestionsinthisapplicationandthatyour
answersaretrueandcorrecttothebestofyourknowledgeandbelief.Thesubmissionofanapplicationcontaininganyfalseor
misleadingstatementsmayresultinthepermanentrefusalofavisaorthedenialofentryintotheUnitedStates.Alldeclarations
madeinthisapplicationareunsworndeclarationsmadeunderpenaltyofperjury.(28U.S.C.1746).
YoucertifiedthatyouunderstandthatyouarerequiredtosubmityourvisatotheUnitedStatesImmigrationOfficerattheport
whereyouapplytoentertheUnitedStates,andthatpossessionofthevisadoesnotentitleyoutoentertheUnitedStatesif,
uponyourarrival,youarefoundtobeinadmissibleunderU.S.immigrationlaws.Youcertifiedthatyouunderstandthatany
willfullyfalseormisleadingstatementorwillfulconcealmentofamaterialfactmadebyyouwithintheapplicationmaysubject
youtopermanentexclusionfromtheUnitedStatesand,ifyouareadmittedtotheUnitedStates,maysubjectyoutocriminal
prosecutionand/ordeportation.
Theinformationthatyouhaveprovidedinyourapplicationandotherinformationsubmittedwithyourapplicationmaybe
accessibletoothergovernmentagencieshavingstatutoryorotherlawfulauthoritytousesuchinformation,includingforlaw
enforcementandimmigrationlawenforcementpurposes.Iffingerprintsarecollectedaspartofyourapplicationprocess,they
maybeusedforthepurposeofcomparingthemtootherfingerprintsintheFBIsNextGenerationIdentification(NGI)fingerprint
systemoritssuccessorsystems(includingcivil,criminal,andlatentfingerprintrepositories).Thephotographthatyouprovide
withyourapplicationmaybeusedforemploymentverificationorotherU.S.lawpurposes.

https://ceac.state.gov/GenNIV/common/printapplication.aspx?BAZbOcZOo5SXGBRZN7IvdkN0a4PRtZCqaO%2f1sBrEC6g%3d

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