FORM FOR B1/ B2 FOR AMERICAN EMBASSY
Personal, Address, Phone, and Passport/Travel Document Information
Name Provided:
Full Name in Native Language:
Other Names Used:
Telecode Name Used:
Gender: Marital Status:
Date of Birth: Place 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 a permanent resident 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
Do you have any additional phone numbers?
Email Address
Do you have any additional email addresses?
Additional Email
Do you have a social media presence?
Social Media Platform: (1):
Social Media Identifier:
Social Media Platform: (2):
Social Media Identifier:
Do you have any additional social media
presence?
Passport/Travel Document Type:
Passport/Travel Document Number:
Passport Book Number:
Country/Authority that Issued Passport/Travel
Document:
Where Issued:
State/Province Where Issued:
Country/Region Where Issued:
Issuance Date: Expiration Date:
Have you ever lost a passport or had one stolen?
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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.:
City, State, Postal/Zip Code:
Person/Entity Paying for Your Trip:
Person Paying for Your Trip:
Telephone Number:
Email Address:
Relationship to You:
Is the address of the party paying for
your trip the same as your Home or
Mailing Address?
Payer's Address:
City:
State/Province:
Postal Zone/ZIP Code:
Country/Region: Are there other
persons traveling with 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withdrawn your application for admission at the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? Explain
U.S. Contact Information
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 Surnames:
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,
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not including parents in the U.S.?
Relative Name (1):
Relationship to you:
Status:
Spouse's Full Name:
Spouse's Date 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/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 Currency (if
employed):
Briefly Describe your Duties:
Were you previously employed?
Have you attended any educational
institutions at a 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:
Name of Institution (2):
Address of Institution:
City:
State/Province:
Postal Zone/ZIP Code:
Country/Region:
Course of Study:
Date of Attendance From:
Date of Attendance To:
Name of Institution (3):
Address of Institution:
City:
State/Province:
Postal Zone/ZIP Code:
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Country/Region:
Course of Study:
Date of Attendance From:
Date of Attendance To:
Name of Institution (4):
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 or tribe?
Provide a List of Languages You Speak:
Language Name (1):
Language Name (2):
Language Name (3):
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):
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