1/23/25, 7:48 PM Consular Electronic Application Center - Print Application

Online Nonimmigrant Visa Application (DS-160)

Application - Sensitive But Unclassified(SBU)

We do not need a printed copy of your application at any point during your interview process. Only print this
application if you want a copy for your own records. If you print your application, please keep it secure.

Photo Provided:

Confirmation Number:

Your Personal Copy -- Do Not Bring to Interview

Personal, Address, Phone, and Passport/Travel Document Information
Name Provided: SILVEIRA SIMOES, GISELE
Full Name in Native Language: DOES NOT APPLY

Other Names Used: NO

Telecode Name Used: NO

Sex: FEMALE
Marital Status: SINGLE
Date of Birth: 03 APRIL 2018
Place of Birth: BRASILIA, DISTRITO FEDERAL, BRAZIL

Country/Region of Origin (Nationality): BRAZIL

Do you hold or have you held any nationality other than the one indicated above on NO
nationality?

Are you a permanent resident of a country/region other than your country/region of NO

origin (nationality) above?

National Identification Number: DOES NOT APPLY

U.S. Social Security Number: DOES NOT APPLY
U.S. Taxpayer ID Number: DOES NOT APPLY

Home Address: SQNW 109 BLOCO I APART 501

NOROESTE

Your Personal Copy -- Do Not Bring to Interview

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Your Personal Copy -- Do Not Bring to Interview

City: BRASILIA

State/Province: DISTRITO FEDERAL

Postal Zone/ZIP Code: 70686445

Country/Region: BRAZIL
Same Mailing Address? YES
Primary Phone Number: 5561981110131

Secondary Phone Number: DOES NOT APPLY

Work Phone Number: DOES NOT APPLY

Do you have any additional phone numbers? NO

Email Address: [email protected]
Do you have any additional email addresses? NO

Do you have a social media presence?

Social Media Platform: (1): None
Social Media Identifier:

Do you have any additional social media presence? NO

Passport/Travel Document Type: REGULAR

Passport/Travel Document Number: GH026281

Passport Book Number: DOES NOT APPLY
Country/Authority that Issued Passport/Travel Document: BRAZIL
City Where Issued: BRASILIA

State/Province Where Issued: DISTRITO FEDERAL

Country/Region Where Issued: BRAZIL
Issuance Date: 31 MAY 2023
Expiration Date: 30 MAY 2028
Have you ever lost a passport or had one stolen? NO

Travel Information
The List of Purposes of Trip to the U.S.
Purpose of Trip to the U.S. (1): TEMP. BUSINESS OR PLEASURE VISITOR (B)
Specify: TOURISM/MEDICAL TREATMENT (B2)

Intended Date of Arrival: 25 MARCH 2025

Intended Length of Stay in U.S.: 10 DAY(S)
Address where you will stay in the U.S.: 5829 GRAND NATIONAL DR
Person/Entity Paying for Your Trip: OTHER PERSON
Person Paying for Your Trip: BOAVENTURA SIMOES , GUSTAVO

Telephone Number: 5561981110131

Email Address: [email protected]
Relationship to You: PARENT
Is the address of the party paying for your trip the same as your Home or Mailing YES
Address?
Are there other persons traveling with you? YES
Are you traveling as part of a group or organization? NO
Persons Traveling with You:

Your Personal Copy -- Do Not Bring to Interview

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Your Personal Copy -- Do Not Bring to Interview

Name (1): BOAVENTURA SIMOES, GUSTAVO
Relationship to You: PARENT

Name (2): SALIM SILVEIRA, LUCIANA

Relationship to You: PARENT
Have you ever been in the U.S.? NO
Have you ever been issued a U.S. visa? NO
Have you ever been refused a U.S. Visa, or been refused admission to the United NO
States, or withdrawn your application for admission at the port of entry?
Has anyone ever filed an immigrant petition on your behalf with the United States NO
Citizenship and Immigration Services?

U.S. Contact Information

Contact Person Name in the U.S.: DO NOT KNOW

Organization Name in the U.S.: CLARION INN & SUITES ACROSS FROM
Relationship to You: OTHER
U.S. Contact Address: 5829 GRAND NATIONAL DR
ORLANDO, FLORIDA 32819
Phone Number: 14073513800

Email Address: DOES NOT APPLY

Family Information
Father's Surnames: BOAVENTURA SIMOES
Father's Given Names: GUSTAVO
Father's Date of Birth: 26 JANUARY 1979

Is your father in the U.S.? NO

Mother's Surnames: SALIM SILVEIRA
Mother's Given Names: LUCIANA
Mother's Date of Birth: 26 MAY 1981
Is your mother in the U.S.? NO

Do you have any immediate relatives, not including parents in the U.S.? NO
Do you have any other relatives in the United States? NO

Security and Background Information

Do you have a communicable disease of public health significance? (Communicable diseases of public significance include NO
chancroid, gonorrhea, granuloma inguinale, infectious leprosy, lymphogranuloma venereum, infectious stage syphilis, active
tuberculosis, and others diseases as determined by the Department of Health and Human Services.)
Do you have a mental or physical disorder that poses or is likely to pose a threat to the safety or welfare of yourself or others? NO
Are you or have you ever been a drug abuser or addict? NO
Have you ever been arrested or convicted for any offense or crime, even though subject of a pardon, amnesty, or other similar NO
action?

Have you ever violated, or engaged in a conspiracy to violate, any law relating to controlled substances? NO

Are you coming to the United States to engage in prostitution or unlawful commercialized vice or have you been engaged in NO
prostitution or procuring prostitutes within the past 10 years?

Have you ever been involved in, or do you seek to engage in, money laundering? NO
Have you ever committed or conspired to commit a human trafficking offense in the United States or outside the United States? NO

Are you the spouse, son, or daughter of an individual who has committed or conspired to commit a human trafficking offense in the NO
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 NO
human trafficking offense in the United States or outside the United States?

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Your Personal Copy -- Do Not Bring to Interview

Do you seek to engage in espionage, sabotage, export control violations, or any other illegal activity while in the United States? NO

Do you seek to engage in terrorist activities while in the United States or have you ever engaged in terrorist activities? NO

Have you ever or do you intend to provide financial assistance or other support to terrorists or terrorist organizations? NO
Are you a member or representative of a terrorist organization? NO

Are you the spouse, son, or daughter of an individual who has engaged in terrorist activity, including providing financial assistance or NO
other support to terrorists or terrorist organizations, in the last five years?

Have you ever ordered, incited, committed, assisted, or otherwise participated in genocide? NO
Have you ever committed, ordered, incited, assisted, or otherwise participated in torture? NO

Have you committed, ordered, incited, assisted, or otherwise participated in extrajudicial killings, political killings, or other acts of NO
violence?

Have you ever engaged in the recruitment or the use of the child soldiers? NO
Have you, while serving as a government official, been responsible for or directly carried out, at any time, particularly severe NO
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 NO
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? NO

Have you ever sought to obtain or assist others to obtain a visa, entry into the United States, or any other United States immigration NO
benefit by fraud or willful misrepresentation or other unlawful means?

Have you ever been removed or deported from any country? NO

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. NO
court?
Have you voted in the United States in violation of any law or regulation? NO

Have you ever renounced United States citizenship for the purpose of avoiding taxation? NO

Location Information
Location where you will be submitting your application
Current Location: BRASILIA, BRAZIL

Preparer of Application
Did anyone assist you in filling out this application? YES

Preparer Surnames: AZPURUA RAGAZZONI

Preparer Given Names: ADELE

Organization Name: GOVASSIST LLC

Street Address: 1629 K ST., SUITE 300

City: WASHINGTON

State/Province: D.C.
Postal Zone/ZIP Code: 20006

Country/Region: UNITED STATES OF AMERICA

Relationship to You: TRAVEL CONCIERGE

Your Personal Copy -- Do Not Bring to Interview

You electronically signed your application on 23-Jan-2025 12:48:51 (GMT-05:00). You were required to electronically sign your application yourself,
unless otherwise exempt by regulation, even if the application was prepared by someone other than yourself. Your electronic signature certifies that you
have read and understood the questions in this application and that your answers are true and correct to the best of your knowledge and belief. The
submission of an application containing any false or misleading statements may result in the permanent refusal of a visa or the denial of entry into the
United States. All declarations made in this application are unsworn declarations made under penalty of perjury. (28 U.S.C. 1746).

You certified that you understand that you are required to submit your visa to the United States Immigration Officer at the port where you apply to enter
the United States, and that possession of the visa does not entitle you to enter the United States if, upon your arrival, you are found to be inadmissible
under U.S. immigration laws. You certified that you understand that any willfully false or misleading statement or willful concealment of a material fact
made by you within the application may subject you to permanent exclusion from the United States and, if you are admitted to the United States, may
subject you to criminal prosecution and/or deportation.

The information that you have provided in your application and other information submitted with your application may be accessible to other government
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1/23/25, 7:48 PM Consular Electronic Application Center - Print Application
agencies having statutory or other lawful authority to use such information, including for law enforcement and immigration law enforcement purposes. If
fingerprints are collected as part of your application process, they may be used for the purpose of comparing them to other fingerprints in the FBI’s Next
Generation Identification (NGI) fingerprint system or its successor systems (including civil, criminal, and latent fingerprint repositories). The photograph
that you provide with your application may be used for employment verification or other U.S. law purposes.

Back: Confirmation Page Print Application

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