SECTION 1 – PERSONAL INFORMATION

Surname (as listed in passport) Vera Diaz

Given Names (first names as listed in passport) Diego Alejandro
Any other names used and why
Dejar en blanco
(e.g. maiden name, professional, religious, alias, etc.)
Sex (male or female) Male

Marital Status Single

Date of Birth (12/ dic./ 1998) 20-May-96

City of Birth Pabellon de Arteaga
State of Birth Aguascalientes
Country of Birth Mexico
Current nationality Mexican
Previous or Dual Nationality (if applicable)
Passport number for other nationality (if applicable)
US social security or tax ID No (if applicable)
PASSPORT ONFORMATION
Passport Number N02927983
Place of issuance (City, State) Aguascalientes, Aguascalientes
Issuance Date 31/may/2022
Expiry Date 31/may/2028
Have you ever lost a passport or had one stolen? If so,
provide passport number, place of issuance and brief No
explanation of circumstances of loss
VACCINE STATUS
Type of vaccine Astra Zeneca

First dose date: 22/july/2021

Second dose date: 28/september/2021

Third dose date (If apply)

Does not Apply

TRAVEL INFORMATION
Purpose of your trip
Intended date of arrival (dd/mm/yyyy) (12/ dic./ 1998)
Length of stay (days)
Address where you will stay in US
Street
City Dejar en blanco
State
Zip
Who will pay for your trip? (self, US petitioner, other)
If other, please state details (names, telephone number,
email address, postal address and relationship to you).
TRAVEL COMPANIONS INFORMATION
Are any other persons travelling with you? (yes/no)
Are you travelling as part of a group? (yes/no) If yes, please Dejar en blanco
provide name of the group
PREVIOUS US TRAVEL INFORMATION
Have you previously visited the US? (yes/no) No
If yes, please provide details for your last 5 visits
1. DD/MM/YYYY length of stay XX days
2. DD/MM/YYYY length of stay XX days
3. DD/MM/YYYY length of stay XX days
4. DD/MM/YYYY length of stay XX days
5. DD/MM/YYYY length of stay XX days
Have you ever held a US drivers licence? (yes/no) No
If yes, please give license number and State.
Have you previously been issued a US visa? (yes/no) No
If yes, please state following details for latest visa:

1. Date visa issued

2. Visa number (if known)

3. Are you applying for same type of visa (yes/no)
4. Are you applying in same country (yes/no)
5. Have you provided all ten fingerprints (yes/no)
Has your US Visa ever been lost or stolen? (yes/no)
If yes, please state year of loss and brief explanation of
circumstances.

Have you ever had a US visa cancelled or revoked? (yes/no) No

If yes, please provide brief explanation of circumstances.

Have you ever been refused a US visa? (yes/no) No

If yes, please provide brief explanation of circumstances.

Have you ever been refused admission to the US or

withdrawn your application for admission at the point of No
entry? (yes/no)
If yes, please provide brief explanation of circumstances.

Have you ever been denied travel authorization by the

Department of Homeland Security through the Electronic No
System for Travel Authorization (ESTA)? (yes/no)
If yes, please provide brief explanation of circumstances.

Has anyone ever filed a Green card application for

No
permanent residence on your behalf? (yes/no)
If yes, please provide brief explanation of circumstances.
SECTION 2 – ADDRESS & PHONE INFORMATION
Home Address
1) Street Felipe Angeles
2) City: Pabellon de Aretaga
3) State: Aguascalientes
4) Post code (Zip): 20676
5) Country Mexico
Mailing address in if different from above
1) Street
2) City:
3) State:
4) Post code (Zip)
5) Country
Home Telephone
Work Telephone
Mobile telephone 4651185527
Email address [email protected]
Social Media Platform (facebook, instagram, etc) Diego Vera Diaz
Social Media Identifier
EMERGENY CONTACT NAME Ma Lourdes Diaz Acosta
EMERGENY CONTACT PHONE 4651015381
FAMILY INFORMATION
Father’s Full Name (even if deceased)
Father's last name: Vera Muñoz
Father's first name: Angel
Father’s Date of Birth (DD,Month, YYYY) (12/ dic./
02/august/1957
1998)
Is your father in the US? (yes/no) No
If yes, please state status: citizen/legal permanent
resident/non-immigrant/other.
Mother’s Full Name (even if deceased)
Mother’s Last Name Diaz Acosta
Mother’s Fisrt Name Ma Lourdes
Mother’s Date of Birth (DD,Month, YYYY) (12/ dic./
19/september/1961
1998)
Is your mother in the US? (yes/no) No
If yes, please state status: citizen/legal permanent
resident/non-immigrant/other.
Do you have any immediate relatives, not including parents,
No
in the United States? (yes/no)
If yes, please state:
1. Full name (First name, Last Name)
2. Relationship to you
3. Status: citizen/legal permanent resident/non-
immigrant/other
Do you have any other relatives in the US? (yes/no) Si
SPOUSE (IF APPLICABLE) INFORMATION
Spouse’s surname
Spouse’s maiden name (if applicable)
Spouse’s first name(s)
Spouse’s date of birth (dd/mm/yyyy) (30/agosto/2020)
Spouse’s nationality
Spouse’s place of birth
1. City
2. Country
Spouse’s full address
1)Street
2)City
3)State
4) Zip (Post code)
Are you divorced (yes/no)

If yes, please state:

1. Date of marriage
2. Date of divorce
3. Grounds for divorce
WORK/EDUCATION/TRAINING INFORMATION

What is your primary occupation? Enginier

Are you self-employed? (yes/no) No

If currently employed, please state current employer’s

details:

1. Employer’s name: Resortes MONTICELLO de Mexico SA. de CV.

2. Employer’s full address AV. Mexico No. 201, Parque Industrial San Francisco
· Street: de los Romos
· City: San Francisco de los Romos
· State: Aguascalientes
· Zip (Post Code): 20300
3. Employer’s telephone number: 4499107012
4. Starting Date (Date, Month, Year) 26/september/2022

5. Monthly salary (in local currency) 16800

6. Job Tile
 Implement preventive, corrective and predictive
maintenance, make work orders, assign and carry out
7. Brief Job Description
scheduled maintenance and ensure continuous
improvement with the PDCA methodology

If previously employed, please state previous employer’s

details:

1. Employer’s name: MABUCHI Motor Mexico

2. Employer’s full address Circuito Cerezos Oriente No. 105, Parque Industrial
· Street: San Francisco IV
· City: San Francisco de los Romos
· State: Aguascalientes
· Zip (Post Code): 20355
3. Employer’s telephone number: 4494783200

4. Job Title Preventive and corrective maintenance of vertical and

horizontal plastic injection molding machinery with
cold and hot casting on JSW, KINKI and FANUC
brand machinery.
Washing, adjustment and maintenance of plastic
injection molds, as well as attending to production
Brief job description
defects and check-list of initial conditions of injection
machinery.
Continuous improvement to ensure the highest quality
of the product and satisfy the established
5. Supervisor Surname requirements
Lopez Aguilarand conditions.
6. Supervisor Given Name Diego
14/september/2020 ~ 23/september/2022
7. Employment Period Date, Month, Year ~ Date,
Month, Year

Please provide details of the High school you attended

1. School name
2. School’s full address
· Street:
· City:
· State:
· Zip (Post Code):
4. Technician degree:
4. Attendance dates Date, Month, Year ~ Date, Month,
Year
Please provide details of University attended:
1. Establishment name Instituto Tecnologico de Pabellon de Arteaga
2. Establishment’s full address Carretera a la estacion de Rincon de Romos,
· Street: kilometro 1
· City: Pabellon de Arteaga
· State: Aguascalientes
 · Zip (Post Code): 20670

3. Attendance dates Date, Month, Year ~ Date, Month, Year 24/agosto/2015 ~ 11/junio/2020

4. Major Mechatronics Engineering

Provide a list of languages that you can speak. Ingles Basico

Please list other countries you have travelled to in the last 5

years.
SECURITY & BACKGROUND

(If you answer “yes” to any of the following security and

background questions, please provide a brief explanation.)

Have you or do you belong to any professional, social or

No
charitable organisations?
Do you have any specialised skills or training such as
No
firearms, nuclear, biological or chemical experience?
Have you ever served in the military? If yes, please give
No
details of branch, rank achieved and dates of service.
Have you ever served in, been a member of, or been
involved with a paramilitary unit, vigilante unit, rebel No
group, guerrilla group or insurgent organisation?
Do you have a communicable disease of public health
No
significance such as Tuberculosis?
Do you have a mental or physical disorder that poses a
No
threat to safety or welfare or yourself or others?
Have you ever been a drug abuser or addict? No
Have you ever been arrested or convicted for any offence or
crime, even though subject of a pardon, amnesty or similar
No
action? If yes, please give full details of date, reason for
arrest and outcome of proceedings.
Have you ever violated, or engaged in conspiracy to violate,
No
any law relating to controlled substances?

Are you coming to the US to engage in prostitution or

unlawful commercialised vice or have you been engaged in No
prostitution or procuring prostitutes in the last 10 years?

Have you ever committed or conspired to commit human

No
trafficking offences in the US?
Have you knowingly aided, abetted, assisted or colluded
with an individual who has committed severe human No
trafficking offences in the US?
Are you the spouse, son or daughter of an individual who
has committed or conspired to commit a human trafficking No
offence in the last 5 years?
Have you ever been involved in, or do you seek to engage in
No
money laundering?
Do you seek to engage in espionage, sabotage, export
control violations, or any other illegal activity while in the No
US?
Do you seek to engage in terrorist activities while in the US
No
or have you ever engaged in terrorist activities?
Have you ever or do you intend to provide financial
assistance or other support to terrorists or terrorist No
organisations?
Are you a member or representative of a terrorist
No
organisation?
Have you ever ordered, incited, assisted or otherwise
No
participated in genocide?
Have you ever ordered, incited, assisted or otherwise
No
participated in torture?
Have you committed, ordered, incited, assisted or otherwise
participated in extrajudicial killings, political killings or No
other acts of violence?
Have you engaged in the recruitment of child soldiers? No
Have you, while serving, been responsible for, or directly
carried out, at any time, particularly severe violations of No
religious freedoms?
Have you ever been involved in the establishment or
enforcement of population controls, forcing a woman to
No
undergo an abortion against her free choice, or a man or
woman to undergo sterilization against his or her free will?
Have you ever been directly involved in the coercive
No
transplantation of human organs of bodily tissue?
Have you ever been the subject of a deportation hearing? No
Have you ever sought to obtain or assist others to obtain a
visa, entry into the US, or any other US immigration benefit
No
by fraud or wilful misrepresentation or other unlawful
means?
Have you failed to attend a hearing on removability or
No
inadmissibility in the last 5 years?
Have you ever been unlawfully present, overstayed the
amount of time granted by an immigration official or
No
otherwise violated the terms of a US visa? If yes, please
give full details.
Have you ever withheld custody of a US citizen child
outside of the US from a person granted legal custody by a No
US court?
Have you ever voted in the US in violation of any law or
No
regulation?
Have you ever renounced US citizenship for the purpose of
No
avoiding taxation?
Have you attended a public elementary school on student F
status or public secondary school after 30 November 1996 No
without reimbursing the school?
 INSTRUCCIONES ESPECIALES DE
LLENADO

Si estas en unión libre pon "Single" a menos que tengas un

documento oficial de concubinato.
Seguir la forma día/mes con letras/año

Solo si cuentas con otra nacionalidad

Ponga la ciudad y estado donde tramito el pasaporte

Seguir la forma día/mes con letra/año (12/ dic./ 1998)

Si tienes mas de un tipo de vacuna, menciona ambos

Seguir la forma día/mes con letra/año (12/ dic./ 1998) y
mencionar el tipo de vacuna
Seguir la forma día/mes con letra/año (12/ dic./ 1998) y
mencionar el tipo de vacuna

Seguir la forma día/mes con letra/año (12/ dic./ 1998) y

mencionar el tipo de vacuna. Si aun no cuentas con tu
refuerzo, favor de mencionarlo.
 Proporciona las fechas de entrada y la duración del viaje
(Puedes consultar la página del i94 en internet, si no se
encuentran alli y hubo registro de entrada si registra el viaje )
Si no recuerdas cuánto tiempo permaneciste en el país o la
fecha, favor de proporcionar un aproximado. Si estuviste de
manera ilegal no pongas los viajes a menos que tuvieras
algun registro o detalle con migracion

Fecha de expedición de tu Visa Seguir la forma día/mes con

letra/año

Unicamente si algun agente oficial cancelo tu visa vigente por

algun problema migratorio.

Contesta SI, unicamente si anteriormente solicitaste una visa

de cualquier tipo ante la embajada y esta fue rechazada
NO uses acentos, comas, guiones, #, etc. Solo letras.

Solo llenar si quieres que tu visa se envié a una dirección

diferente a la que pusiste arriba, si es la misma dirección que
proporcionaste en las sección Home address, no la pongas 2
veces y deja este espacio en blanco. NO uses acentos,
comas, guiones, #, etc. Solo letras. Se seleccionara la
ubicacion de DHL mas cercana a esta direccion

Números sin lada ni espacios, UNICAMENTE 10 DIGITOS, si

no cuentas con número de casa y/o trabajo deja esos
espacios en blanco, no repitas los números.

Solo pon el nombre de la red social

Puede ser usuario o link
Persona que podremos contactar en alguna emergencia
UNICAMENTE 10 DIGITOS

AMBOS APELLIDOS
NOMBRE
Seguir la forma día/mes con letra/año

AMBOS APELLIDOS
NOMBRE

Seguir la forma día/mes con letra/año

AMBOS APELLIDOS
NOMBRE
Seguir la forma día/mes con letra/año (en ingles)

Si tu esposa vive en la misma dirección que ya

proporcionaste en el apartado Home address deja este
espacio en blanco

Profesión - Coloca tu grado de estudios (ENGINIER O

TECHNICIAN) Segun sea el caso.

Forzosamente debe haber una respuesta ya sea si o no

Si no tienes empleo actual debes colocar el empleo

inmediato anterior (relacionado con tu carrera profesional)
NO PONGAS EMPLEOS DE MAESTRO, NI AUTO EMPLEOS

Nombre de la empresa NO PONGAS NOMBRES DE PERSONAS

NO uses acentos, comas, guiones, #, etc. Solo letras.

Números sin lada ni espacios, UNICAMENTE 10 DIGITOS

CAMPO OBLIGATORIO
Seguir la forma día/mes con letra/año

Salario mensual en PESOS MEXICANOS, RANGO (15000-

30000) si tu sueldo no esta en este rango pon una cantidad
que se encuentre dentro de este rango

Si eres ingeniero no coloques un puesto menor a este rango,

si eres técnico coloca un puesto de técnico relacionado a tu
carrera profesional
Obligatorio llenar con actividades que se relacionen
directamente con tu carrera profesional, si es necesario
adaptalas. Ejemplo si eres ingeniero quimico y desempeñas
actividades de industrial, pon lo que puede hacer un quimico
en la industra (recuerda que trabajaras en una industria
automotríz o en su defecto el tipo de industria en el que
trabajaras)

Si tu empleo anterior lo pusiste como empleo actual coloca

aquí un empleo previo a ese pero igual relacionado con tu
carrera profesional
Nombre de la empresa NO PONGAS NOMBRES DE PERSONAS

NO uses acentos, comas, guiones, #, etc. Solo letras.

Números sin lada ni espacios, UNICAMENTE 10 DIGITOS

CAMPO OBLIGATORIO
Si eres ingeniero no coloques un puesto menor a este rango,
si eres técnico coloca un puesto de técnico relacionado a tu
carrera profesional

Obligatorio llenar con actividades que se relacionen

directamente con tu carrera profesional, si es necesario
adaptalas. Ejemplo si eres ingeniero quimico y desempeñas
actividades de industrial, pon lo que puede hacer un quimico
en la industra (recuerda que trabajaras en una industria
automotríz o en su defecto el tipo de industria en el que
trabajaras)
AMBOS APELLIDOS
NOMBRE /S

Seguir la forma día/mes con letra/año (en ingles), Si fue

necesario poner empleos anteriores haz las modificaciones
necesarias en las fechas (TAMBIEN MODIFICAR CV)

SI tienes universidad no es necesario llenar esta sección, a

menos que estes aplicando como técnico nivel medio
superior

NO uses acentos, comas, guiones, #, etc. Solo letras y num

Solo si tu prepa ofrece carrera tecnica

NO uses acentos, comas, guiones, #, etc. Solo letras y num

NOMBRE DE LA CARRERA ESTUDIADA Tal y como esta en tu
titulo expedido por la universidad pero traducido al ingles
Ejemplo. Ingeniero industrial y de Sistemas = Industrial and
Systems Engineering

En esta sección la respuesta debera ser siempre NO