5728123, 10:19AM Consular Electronic Applicaton Genter - Print Applicaton Siguiente 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: | AAVOBVZGA - Do Not Bring to Interview Your Personal Copy 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: Place of Birth Country/Region of Origin (Nationality): Do you hald or have you held any nationality other than the one indicated above on nationality? [Are you a permanent resident of a country/region other than your country/region of origin (nationality) above? National Identification Number: US. Social Security Number: USS. Taxpayer 1D Number: Home Address: city: State/Province: Postal Zone/ZIP Code: Country/Region: Your Personal Copy FALLA VALDIVIA, MARIA DEL PILAR DOES NOT APPLY No No FEMALE MARRIED. 08 JUNE 1966 LIMA, LIMA, PERU. u No No 06671795, DOES NOT APPLY DOES NOT APPLY AV. SURCO 360 A DPTO 2 uma uma DOES NOT APPLY RU - Do Not Bring to Interview itpsscnac. stato. goviGunNIVicommoniprintappicabon aspx?SW24X0vbOvCnHHbYrHC7D3PGEpWATELYESByNCgoMM36 1185728123, 10:19AM ‘Consular Electronic Applicaton Genter - Print Applicaton Your Personal Copy Same Mailing Address? Primary Phone Number: Secondary Phone Number Work Phone Number: Do you have any adcitional phone numbers? Adaitional hone: (1) Email Address bo you have any aditional email addresses? Additonal Email (1) Do you have a social media presence? Socil Media Platform: (2) Social Media Identifier: Sociel Media Platform: (2): Social Media Identifier: Do you have any adcitional social mecie presence? Possport/Tavel Document Type: Possport/Travel Document Number Passport Book Number Country/Authorty that Issued Passpor/Travel Document City wnere Issued State/Province Where Issued Country/Region Where Issued! Issvance Date: Exoiration Date Have you ever lost @ passport or had one stolen? Travel Information ‘The List of Purposes of Trip to the U.S. Purpose of Trip to the U.S. (1) specify Have you made specific travel plans? Intended Date of Arrival: Intended Length of Stay in U.S. Address where you will stay in the U.S. Gity, State, Postal/Zip Code: Person/Entity Paying for Your Tip Person Paying for Your Trip Telephone Number: Email Address: Relationship to You: Your Personal Copy - Do Not Bring to Interview ves 0051946112869 DOES NOT APPLY DOES NOT APPLY ves 005197749865 pilar_falla_1@hotmail.com ves PILARFALLA.86@GMAIL,COM FACEBOOK PIFAVA INSTAGRAM. FALLAVALDIVIA No REGULAR 122321682 DOES NOT APPLY 15 SEPTEMBER 2022 15 SEPTEMBER 2027 No ‘TEMP, BUSINESS PLEASURE VISITOR (8) BUSINESS & TOURISM (TEMPORARY VISITOR) (81/62) No 10 JANUARY 2026 14 DAv(S) 1901 W BUENA VISTA DR, LAKE BUENA VISTA ORLANDO, FLORIDA 32830 OTHER PERSON RODRIGUEZ QUIS 0051982251790 HUGO MARTIN hhugora@gmail.com SPOUSE - Do Not Bring to Interview itpsscnac. stato. goviGunIVicommoniprintappicabon aspx?SW24X0vbOvCnHHbYrHC7D3PGEpWAELYXESByNCgOMM36 216,5728123, 10:19AM ‘Consular Electronic Applicaton Genter - Print Applicaton Your Personal Copy - Do Not Bring to Interview Is the acidress of the party paying for your trip the same as your Home YES oF Mailing Address? Are there other persons traveling with you? Are you traveling as part of a group or organization? Persons Traveling with You: Name (2): Relationship to You: 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 port of entry? Has anyone ever filed an Immigrant petition on your behalf with the United States Citizenship and Immigration Services? U.S. Contact Informati n Contact Person Name 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 Sumames: 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 other relatives in the United States? ‘Spouse's Full Name: ‘Spouse's Dete of Birth ‘Spouse's Country/Region of Origin (Nationality) Spouse's City of Birth ‘Spouse's Country/Region of Birth: Spouse's Address: Work/Education/Trai Primary Occupation: ing Information Were you previously employed? Your Personal Copy ves No RODRIGUEZ QUIS! spouse HUGO MARTIN No No No No 0 Nor KNow WALT DISNEY WORLD OTHER 1901 W BUENA VISTA DR, LAKE BUENA VISTA ORLANDO, FLORIDA 32830 0014079393476 DOES NOT APPLY FALLA CACEDA JAVIER AGUSTIN 03 DECEMBER 1926 No VALDIVIA PALACIOS LUISA TERESA 10 OCTOBER 1934 No. No No RODRIGUEZ QUIS! 05 MARCH 1966 SPAIN uma RU SAME AS HOME ADDRESS HUGO MARTIN HOMEMAKER ves - Do Not Bring to Interview itpsscnac. stato. goviGunIVicommoniprintappicabon aspx?SW24X0vbOvCnHHbYrHC7D3PGEpWAELYXESByNCgOMM36 365728123, 10:19AM Your Personal Copy Employer Name (1) Employer Address: city State/Province: Postal Zone/Zip Code: Country/Region: ‘Telephone Number: Jeb Tile Supervisor's Surname: Supervisor's Given Name: Employment Date From: Employment Date To: Briefly describe your duties: Have you attended any educational institutions at @ secondary level or above? Name of Institution (1) Address of institution city State/Province: Postal Zone/ZIP Code: Country/Region: Course of Study: Date of Attendance From: Date of Attendance To: Do you belong to a clan ar tribe? Provide a List af Languages You Speak Language Name (1) Have you traveled to any countries/regions within the last five years? Provide a List of Countries/Regions Visited Country/Region (1) Country/Region (2) Country/Region (3) Country/Region (4) Country/Region (5) Country/Region (6) Your Personal Copy ‘Consular Electronic Applicaton Genter - Print Applicaton - Do Not Bring to Interview ‘SEGURITEMP PASEO DE LA REPUBLICA 5220 uma uma DOES NOT APPLY PERU 4467077 'SECRETARIA GUZMAN NEGRI ALEJANDRO JOSE (01 JUNE 1988 (01 FEBRUARY 1994 MANEIO DE AGENDA DE CARGOS SUP. ERIORES, COMUNICACION CON PROV EEDORES Y ASOCIADOS, ATENCION {AL PUBLICO Y MANEIO DE DOCUMEN, TACION DE LA EMPRESA ves INSTITUTO PERUANO CANADIENSE GARCILAZO DE LA VEGA 1120, uma uma DOES NOT APPLY PERU ‘SECRETARIADO EJECUTIVO 01 MARCH 1984 on Juty 1985 No ESPANOL, ves SPAIN SWITZERLAND NETHERLANDS FRANCE ARGENTINA cue - Do Not Bring to Interview itpsscnac. stato. goviGunIVicommoniprintappicabon aspx?SW24X0vbOvCnHHbYrHC7D3PGEpWAELYXESByNCgOMM36 46,5728123, 10:19AM ‘Consular Electronic Applicaton Genter - Print Applicaton Your Personal Copy -- Do Not Bring to Interview Have you belonged to, contributed to, or worked for any professional, NO social, or charitable arganization? Do you have any specialized skills or training, such as firearms, No explosives, nuclear, biological, or chemical experience? Have you ever served in the military? No Have you ever served in, been @ member of, or been involved with a NO paramilitary unit, vigilante unit, rebel group, guerrilla group, or Insurgent organization? Security and Background Information Do you have 2 communicable disease of public health significance? (Communicable ¢iseases of public significance Include 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? Are you or have you ever been a drug abuser or addict? Have you ever been arrested or convicted for any offense or 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 commercialized vice or have you been engaged in prostitution or procuring prostitutes within the past 10 years? Have you ever been involved 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 a human trafficking offense in the United States or outsice the United States and have yu 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 Unites States? Do you seek to engage in espionage, sabotage, export control violations, or any other illegal activity while in the United States? Do you seek to engage in terrorist activities while in the United States or have you ever engaged in terrorist activities? Have you ever or de you intend to provide financial assistance or other support to terrorists or terrorist organizations? ‘Are you a member or representative of a terrorist organization? Are you the spouse, son, or daughter of an individual who has engaged in terrorist activity, including providing Financial assistance or other support to terrorists or terrorist organizations, in the last five years? 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, politcal killings, or other acts of vielence? Have you ever engaged in the recruitment 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 waman to undergo an abortion against her free choice or a man or a woman to Undergo sterlization 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 Your Personal Copy -- Do Not Bring to Interview |nttps:l/ceac. state.goviGenNI Vicommon/printapplicaton.aspx?SwZqXbvbOvCnHHb YrHC7D3PGSpWATELY XE6ByhCgoMM%30, No No No No No No No No No No No No No No No No No No No No No No No 5165728123, 10:19AM ‘Consular Electronic Applicaton Genter - Print Applicaton Your Personal Copy -- Do Not Bring to Interview States immigration benefit by fraud or wilful 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 chilé outside the United States from a person granted legal No custody by a U.S. 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 LUMA, PERU Preparer of Application Did anyone assist you in filing out this application? No Your Personal Copy -- Do Not Bring to Interview Usted firmé su solicitud de manera electrénica el 24-Mar-2023 07:19:11 (GMT-05:00). Se le requirié firmar su solictud personalmente y de manera electrénica al menos que par reglamento quede exento de ello y aun si el formulario fue elaborado a su hombre por alguien mas. Su firma electrénica certifica que usted ha leido y entendido las preguntas en su solictud de Visa de No- Inmigrante y que ademés todas sus respuestas son verdaderas y realizadas a su mejor entender y conviccién. La entrega de una solicitud conteniendo declaraciones falsas y engafiosas pueden resultar en la negativa permanente de una visa para entrar a los, Estados Unidos de Norteamérica, Todas las declaraciones hechas en esta solcitud no estan sujetas @ juramento pero deben ser hechas bajo proteste de decir verdad, (28 U.S.C. 1746). La informacién que usted ha proporcionade en su solcitud y alguna otra enviada junto con ésta, puede ser puesta a disposicién de tras agencias del gobierno con el derecho y la autoridad legal que les confiere para usar ¢icha informacién, ineluso para propésitos el érden pablico y leyes de inmigracién. Sise obtienen huellas dactilares como parte de su proceso de solcitud, éstas pueden ser lsadas con el propésito ce compararlas con atvas hucllas dactilares en el Sistema de Identiieacién de Siguiente Generacién (Next Generation Identification System) NGI por sus siglas en inglés, de la Oficina Federal de Investigacién (Federal Bureau of Investigation - FBI por sus siglas en inglés) 0 por sus sistemas subsecuentes (incluyendo civles, criminales y archivos existentes de huellas dactilares). La fotografia que proporcione junto con su solictud puede ser utlizada para verficacién de empleo u otros Dropésitos competentes @ la legislacién de las Estados Unidos de Norteamérica, itpsscnac. stato. goviGunNIVicommoniprintappicabon aspx?SW24XbvbOvCnHHbYrHC7D3PGEpWATELYXESByHCgoMM36 66