Please fill out the form as accurately and truthfully as possible. Use BLOCK capitals to answer the questions.

1. FULL NAME: __________________________________________________________________

2. SEX:_____________________________________________________________________

3. MARITAL STATUS: _____________________________________________________________

4. DATE OF BIRTH: ______________________________________________________________

5. PARISH OF BIRTH: _____________________________________________________________

6. NATIONALITY: ________________________________________________________________

7. HOME ADDRESS: ______________________________________________________________

8. TEL. NO.______________________________________________________________________

9. HAVE YOU USED ANY ADDITIONAL PHONE NUMBERS IN THE LAST 5 YEARS? YES_______ NO_______

IF SO, WHAT IS THE NUMBER? _________________________________

10. EMAIL ADDRESS: ______________________________________________________________

11. SOCIAL MEDIA PLATFORM USED:________________________________________________

12. NAME ON SOCIAL MEDIA PLATFORM? _________________________________________

13. HAVE YOU USED ADDITIONAL SOCIAL MEDIA PLATFORMS IN THE LAST 5 YEARS? YES____ NO____

IF SO, NAME OF SOCIAL MEDIA PLATFORM USED AND YOUR ACCOUNT NAME?

______________________________________________________________________________________________________
Olivia Newman
14. COPY OF PASSPORT: _________________________________________________________

15. OVERSEAS ADDRESS WHERE YOU WILL BE STAYING:

_____________________________________________________________________________

16. POSTAL ZONE/ZIP CODE OF THAT ADDRESS: _______________________________________________

17. WILL YOU BE STAYING WITH SOMEONE? YES________ NO ________________

IF SO, WHAT IS THEIR FULL NAME AND NUMBER? ___________________________

18. WHAT IS YOUR RELATIONSHIP TO THE PERSON:________________________________________

19. ARE YOU BILINGUAL YES __________ NO __________

20. IF YES WHAT IS THE NAME OF THE LANGUAGE YOU SPEAK:____________________________

21. FATHER’S NAME AND DATE OF BIRTH(DAY/MONTH/YEAR):

_____________________________________________________________________________________________
Please fill out the form as accurately and truthfully as possible. Use BLOCK capitals to answer the questions.

22. DOES YOUR FATHER LIVE IN THE U.S? YES ______ NO _______

23. WHAT IS HIS STATUS IN THE U.S(CITIZEN ETC)? __________________________________________________

24. MOTHER'S NAME AND DATE OF BIRTH(DAY/MONTH/YEAR):

__________________________________________________________________________________________

25. DOES SHE LIVE IN THE U.S? YES___________ NO ______________

26. WHAT IS HER STATUS IN THE U.S(CITIZEN ETC)? __________________________________________________

27. DO YOU HAVE ANY IMMEDIATE RELATIVES, NOT INCLUDING PARENTS IN THE U.S(SIBLINGS, CHILDREN,

HUSBAND)? _______________________________________________

28. DO YOU HAVE ANY OTHER RELATIVES IN THE U.S? YES _____________ NO ________________

29. WHO WILL BE SPONSORING YOUR TRIP? SELF __________ OTHER ___________ ORGANIZATION ___________

30. WHAT IS YOUR RELATIONSHIP WITH THE PERSON? _________________

31. WHAT IS THEIR FULL NAME, DATE OF BIRTH, TELEPHONE NUMBER, NATIONALITY, CITY OF BIRTH AND

ADDRESS? ____________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

32.HAVE YOU EVER BEEN IN THE U.S? YES________ NO _________

33. HAVE YOUR EVER BEEN ISSUED A U.S VISA? YES_______ NO _________

34. HAVE YOU EVER BEEN REFUSED A U.S VISA, OR BEEN REFUSED ADMISSION TO THE U.S, OR WITHDRAWN

YOUR APPLICATION FOR ADMISSION AT THE PORT OF ENTRY? YES ___________ NO ____________

IF SO WHY WERE YOU REJECTED? ______________________________________________________

35. HAS ANYONE FILED AN IMMIGRANT PETITION ON YOUR BEHALF WITH THE UNITED STATES CITIZENSHIP

AND IMMIGRATION SERVICES? _____________________________________________

36. WHAT IS YOUR PRIMARY OCCUPATION? _________________________________________________

37. BRIEFLY DESCRIBE YOUR DUTIES?

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

38. WHAT IS YOUR CURRENT SALARY(ANNUALLY/YEARLY)? ________________________________

39. NAME OF EMPLOYER AND ADDRESS?

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

40. TELEPHONE NUMBER OF EMPLOYER? _______________________________________

41. WHEN DID YOU START WORKING FOR YOUR EMPLOYER? ___________________________________

42. WERE YOU PREVIOUSLY EMPLOYED? YES __________ NO ______________

43. EMPLOYER NAME, PHONE NUMBER AND ADDRESS?

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

44. WHAT WAS YOUR JOB TITLE? ______________________________________

45. BRIEFLY DESCRIBE YOUR DUTIES?

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

46. SUPERVISOR’S FULL NAME AND PHONE NUMBER?

______________________________________________________________________________________________________

______________________________________________________________________________________________________

47. EMPLOYMENT DATE FROM AND TO WHEN? DAY/MONTH/YEAR

______________________________________________________________________________________________________
Please fill out the form as accurately and truthfully as possible. Use BLOCK capitals to answer the questions.

48. HAVE YOU ATTENDED ANY EDUCATIONAL INSTITUTIONS AT A SECONDARY LEVEL OR ABOVE? YES __ NO __

49. NAME OF INSTITUTION? _____________________________________________

50. EDUCATIONAL LEVEL OF STUDY (TERTIARY OR SECONDARY)? ______________________________

51. COURSE OF STUDY? _____________________________________________

52. DATE OF ATTENDANCE FROM AND TO WHEN? DAY/MONTH/YEAR

__________________________________________________________________________________________________

53. HAVE YOU TRAVELED TO ANY COUNTRIES/REGIONS WITHIN THE LAST 5 YEARS? YES _____ NO _____

IF SO WHERE AND WHEN (MONTH/YEAR)? ___________________________________

54. HAVE YOU BELONGED TO, CONTRIBUTED TO, OR WORKED FOR ANY PROFESSIONAL, SOCIAL, OR

CHARITABLE ORGANIZATION? YES ______ NO ______

IF SO NAME OF ORGANIZATION, ADDRESS AND PERIOD OF WORKING(FROM WHEN TO WHEN)?

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

55. HAVE YOU EVER SERVED IN THE MILITARY AND HOW LONG DID YOU SERVE(FROM WHEN TO WHEN)?

________________________________________________________________________________________________

56. HAVE YOU EVER LOST A PASSPORT OR HAD ONE STOLEN? YES ___________ NO ______________

Signature of applicant: ______________________________________ Date: _________________