Personal info 1

1. Last name _______________________________

2. First name ____________________________

3. Middle name ___________________________

4. Sex ___________

5. Marital status _________________________

6. Date of birth DD_________MM _________YY____________

7. Country of birth _______________________

8. Other nationality ______________________

9. TRN ____________________________________

Travel details

10. Intended date of arrival DD ___________MM_________YY_________

11. Intended length of stay ____________________

12. Address where you will be staying in the USA ______________________________________________

13. Paying for your trip: Self _________ if other person, please indicate below

Name of person paying for your trip: Last name ____________________First name_____________________

Telephone#______________________

Relationship to you ____________________________

Address ____________________________________________________________________________

14. Other person traveling with you ______ If yes, State name/s, ________________________

15. Are you traveling as part of a group? If yes, State group name _________________________________
Visa info
16. Have you ever been in the USA _______________ if yes, please provide last five visit
Date Month Year ________/_________/____________
Date Month Year ________/_________/____________
Date Month Year ________/_________/____________
Date Month Year ________/_________/____________
Date Month Year ________/_________/____________

17. Have you ever been issued a US visa _________ if yes, please provide the last visa issue
Date Month Year ________/_________/____________

Visa Number ______________________________

18. Have you ever refuse a visa/refuse admission/withdrawn application for admission at the port of entry _

If yes, please explain _________________________________________________________________

Personal info 2
19. Home address ________________________________________________________________________

20. Telephone number/s 1_______________________2 _______________________

21. Do you have Social media_______ if yes, which one _____________Name_______________________

22. Passport number ____________________________

Issue: Date Month Year ________/_________/____________

23. Have you ever lost a passport ________if yes, Please explain __________________________________

24. Contact person name in the USA last name ____________________ first name___________________

25. Organization name in the USA ________________________________________________________

26. Relationship to you _________________________________

27. USA contact address ___________________________________________Phone # ________________

28. Email address _________________________________________________________________

Father: Date of birth: Date Month Year ________/_________/____________

Father: In the USA: ____________ if yes, state his status ____________________________________

30. Mother name: Last _____________________________First_______________________________

Mother date of birth: Date Month Year ________/_________/____________

Mother in the USA: _____________ if yes, state her status ____________________________________

31. Any other immediate relative in the USA: _______ if yes, name _______________________________

Relationship to you ____________________________ Status _________________________________

Spouse name Last name_____________________ First name ______________________________

DOB DD __________MM__________YY____________

Address ___________________________________________________________

Occupation ____________________

Work/School info

32. Occupation ______________________________

33. Present employer/school name: ________________________________________________

34. Address: ___________________________________________________________________________

Start date ______________________

Telephone # ______________________

Salary (_________________________)
 Describe your duties ___________________________________________________________________

35. Previously employed _________ if yes where? _____________________________________________

Address ___________________________________________________________________________

Start date____________________ end date __________________

Telephone #: ______________________________

Describe duties ______________________________________________________

36. Have you attend any high school or above ____________ if yes, where __________________________

Address ____________________________________________________________________________

Course of study _____________________

Start date __________________ end date _____________________

37. Have you travelled to any countries within the last five years ________ if yes, where _______________