U.S Visa Questioner: Personal, Address, Phone, and Passport/Travel Document Information
Uploaded by
Anonymous ku7POqvKU.S Visa Questioner: Personal, Address, Phone, and Passport/Travel Document Information
Uploaded by
Anonymous ku7POqvKU.
S VISA QUESTIONER
Personal, Address, Phone, and Passport/Travel Document Information
Name Provided:
Full Name in Native Language:
Other Names Used:
Telecode Name Used:
Sex:
Marital Status:
Date of Birth:
Country/Region of Origin (Nationality):
Do you hold or have you held any nationality other
than the one indicated above on nationality?
Are you permanent residents of a country/region
other than your country/region of origin
(nationality) above?
National Identification Number:
U.S Social Security Number:
U.S Taxpayer ID Number:
Home Address:
City:
State/Province:
Postal Zone /ZIP Code:
Country/Region:
Same Mailing Address?
Primary Phone Number:
Secondary Phone Number:
Work Phone Number:
Email Address:
Passport/Travel Document Type:
Passport/Travel Document Number:
Passport Book Number:
Country/Authority that Issued Passport/Travel
Documents:
City Where Issued:
Country/Region Where Issued:
Issuance Date:
Expiration Date:
Have you ever lost a passport or had one stolen?
Travel Information:
The List of Purpose of Trip to the U.S
Purpose of Trip to the U.S (1):
Specify:
Intended Date of Arrival:
Intended Length of Stay in U.S:
Address where you will stay in the U.S:
City, State, Postal/Zip Code:
Person/Entity Paying for your trip:
Company/Organization Paying for your trip:
Telephone Number:
Relationship to you:
Address of Company/Organization Paying:
City:
State/Province:
Postal Zone /ZIP Code:
Country/Region:
Are
Are there other Persons
out traveling as part travelling withoryou?
of the group
organization?
Name of the Group:
Have you ever been in the U.S?
Have you ever been issued a U.S Visa?
Have you ever been refused a U.S . Visa, or been
refused admission to the United States, or
withdrawn your application for admission at the
pport of entry?
Has anyone ever filed an immigrant petition on
your behalf with the United States Citizenship and
Immigration Services?
U.S Contact Information
Contact Person in the U.S:
Organization Name in the U.S:
Relationship to you:
U.S Contact Address:
Phone Number:
Email Address:
Family Information:
Father's Surname:
Father's Given Names:
Father's Date of Birth:
Is your father in the U.S?
Mother's Surnames:
Mother's Given Names:
Mother's Date of Birth:
Is your Mother in the U.S?
Do you have any immediate relatives, not including
parents in the U.S?
Do you have any relatives in the United States?
Work/Education/Training Information
Primary Occupation:
Present Employer or School Name:
Address:
City:
State/Province:
Postal Zone /ZIP Code:
Country/Region:
Work Phone Number:
Monthly Salary in Local Curency (if employed):
Briefly Describe your Duties:
Security and Background Information
Do you have a communicable diseaseof public
health significance? (Communicable disease of
public significance include chancroid, gonorrhea,
granuloma Inguinale, infectious leprosy,
lymphogranuloma venerum, infectious stage
syphilis, active tubercolosis, and other disease as
determine by the Department of Health and
HumanServices.)
Do you have a mental or physical disorder that
poses or is likely to pose a threat to the safety or
welfare
Are you of
or yourself
have youorever
others?
been a drug abuser or
addict?
Have you ever been arrested or convicted for any
offense of crime, even though subject of a pardon,
amnesty, or other similar action?
Have you ever violated , or engaged in a conspiracy
to violate, any law relating to controlled
substances?
Are you coming to the United States to engage in
prostitution or unlawful commercialize vice or have
you been engaged in prostitution or procuring
prostitutes within the past 10 years?
have you ever been involve in, or do you seek to
engage in money laundering?
Have you ever committed or conspired to commit a
human trafficking offense in the United States or
outside the United States?
Are you the spouse, son, or daughter of an
individual who has committed or conspired to
commit human trafficking offense in the United
States or outside the United States and have you
within the last five years, knowingly benefited from
the trafficking activities?
Have you knowingly aided, abetted,assisted or
colluded with an individual who has committed or
conspired to commit a severe human trafficking
offense in the United States or outside the United
States?
Do oyu seek to engage in esplonage, sabotage,
expert control violations, or any other illegal
activity while in the United States?
Do you seek to engage in the terorist activities
while in the United States or have you ever
engaged in terrorist activities?
Have you ever or do you intend to provide financial
assistance or other support to terrorist or terrorist
organizations?
Are you a memlber or representative of a terrorist
organization?
Have you ever ordered, incited, committed,
assisted, or otherwise participated in genocide?
Have you ever committed, ordered, incited,
assisted, or otherwise participated in torture?
Have you committed , ordered, incited, assisted, or
otherwise participated in extrajudicial killings,
pollitical killings, or other acts of violence?
Have you ever engaged in the recuitment or the
use of the child soldiers?
Have you, while serving as a government official,
been responsible for or directly carried out, at any
time particularly severe violations of religious
freedom?
Have you ever been directly involved in the
establishment or enforcement of the population
controls forcing a woman to undergo an abortion
against her free choice or a man or a woman to
undergo sterilization against his or her free will?
Have you ever been directly involved in the
coercive transplantation of human organs or bodily
tissue?
Have you ever sought to obtain or assist others to
obtain a visa, entry into the United States, or any
other United states immigration benefit by fraud or
willful misrepresentation or other unlawful means?
have you ever withheld custody of a U.S citizen
chils outside the United States from a person
granted a legal custody by a U.S court?
Have you voted in The United States in violation of
any law or regulation?
Have you ever renounced United States citizenship
for the purpose of avoiding taxation?
Location Information
Location where you will be submitting your
application
Current Location:
Preparer of Application
Did anyone assist you in filling out this application?
Preparer Surnames:
Preparer given Names:
Organization Name:
Street Address:
City:
State/Province:
Postal Zone /ZIP Code:
Country/Region:
Relationship to you:
