Confirmation Number:
Your Personal Copy -- Do Not Bring to
Interview
Personal, Address, Phone, and Passport/Travel Document Information
Full Name in Native Language: Omozogie Osaro Junior
Other Names Used: Omozogie Osaro Junior
Telecode Name Used:
Date of Birth: October /09/1995
Place of Birth: Edo State
Country/Region of Origin
Nigeria
(Nationality):
Do you hold or have you held any
nationality other than the one No
indicated above on nationality?
National Identification Number: 21676041199
U.S. Social Security Number:
U.S. Taxpayer ID Number:
No 15 Aurosaghe Street off Tv
Home Address:
Road B/c
City: Benin city
State/Province: Edo state
Postal Zone/ZIP Code: 300102
Country/Region: Nigeria
Same Mailing Address? Yes
Primary Phone Number:+ +2347025535919
Secondary Phone Number:
Work Phone Number: +2347025535919
Email Address: Osaroomozogie@gmail.com
Passport/Travel Document Type: Standard
Passport/Travel Document Number: B02843250
Passport Book Number: B02843250
Country/Authority that Issued
Nigeria
Passport/Travel Document:
City Where Issued: Benin City
State/Province Where Issued: Edo State
Country/Region Where Issued: Nigeria
Issuance Date: 16th October 2023
Expiration Date: 15th October 2028
Have you ever lost a passport or
No
had one stolen?
Travel Information
The List of Purposes of Trip to the U.S.
Visiting USA to Attend The Third
Purpose of Trip to the U.S. (1):
Muslim Scouts Jamboree
Third Muslim Scourts Jamboree
Specify:
2024
Have you made specific travel
Yes
plans?
Intended Date of Arrival: June 28th 2024
Intended Length of Stay in U.S.: 14 days( 2 weeks)
Address where you will stay in the
U.S.:
City, State, Postal/Zip Code:
Person/Entity Paying for Your Trip: Scourts association of Nigeria
Are there other persons traveling
Yes
with you?
Are you traveling as part of a group Yes Traveling has a Group
or organization? Scouts association
of Nigeria
Persons Traveling with You:
Name (1): Omozogie Osayamen Cynthia
Relationship to You: Siblings
Name (2):
Relationship to You:
Name (3):
Relationship to You:
Have you ever been in the U.S.? No
Have you ever been issued a U.S.
No
visa?
Have you ever been refused a U.S.
Visa, or been refused admission to
the United States, or withdrawn No
your application for admission at
the port of entry?
Explain:
Has anyone ever filed an immigrant
petition on your behalf with the
No
United States Citizenship and
Immigration Services?
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: Omozogie
Father's Given Names: Kenendy
Father's Date of Birth: April 26 1960
Is your father in the U.S.? No
Mother's Surnames: Enabulele
Mother's Given Names: Isoken
Mother's Date of Birth: December/15/1976
Is your mother in the U.S.? No
Do you have any immediate
relatives, not including parents in No
the U.S.?
Do you have any other relatives in
No
the United States?
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: Aluminium Fabricator
Fabricatiom of Aluminium doors,
Specify Other:
windows and roofing sheets
Present Employer or School Name: Odion Aluminium Company
56 4th Victor street off New lagos
Address:
road
City: Benin City
State/Province: Edo State
Postal Zone/Zip Code: 300102
Country/Region: Nigeria
Work Phone Number: 08081406055
Monthly Salary in Local Currency (if
employed):
Briefly Describe your Duties:
Were you previously employed?
Have you attended any
educational institutions at a Yes
secondary level or above?
Name of Institution (1): Ighogbe Secondary School
Address of Institution:
City: Benin
State/Province: Edo
Postal Zone/ZIP Code: 300102
Country/Region: NIGERIA
Course of Study:
Date of Attendance From:
Date of Attendance To:
Do you belong to a clan or tribe? Trib
Provide a List of Languages You Speak:
Language Name: (1): BINI
Language Name: (2): Hausa
(3): English
Have you traveled to any
No
countries within the last five years?
Country/Region Visited (1):
Have you belonged to, contributed
to, or worked for any professional, Yes
social, or charitable organization?
Do you have any specialized skills
or training, including firearms,
No
explosives, nuclear, biological, or
chemical experience?
Have you ever served in the
No
military?
Have you ever served in, been a NO
member of, or been involved with a
paramilitary unit, vigilante unit,
rebel group, guerrilla group, or
insurgent organization?
Security and Background Information
Do you have a communicable disease of public health significance?
(Communicable diseases of public significance include chancroid,
gonorrhea, granuloma inguinale, infectious leprosy,
NO
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
NO
pose a threat to the safety or welfare of yourself or others?
Are you or have you ever been a drug abuser or addict? NO
Have you ever been arrested or convicted for any offense or crime,
NO
even though subject of a pardon, amnesty, or other similar action?
Have you ever violated, or engaged in a conspiracy to violate, any
NO
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 NO
prostitution or procuring prostitutes within the past 10 years?
Have you ever been involved in, or do you seek to engage in,
NO
money laundering?
Have you ever committed or conspired to commit a human
trafficking offense in the United States or outside the United NO
States?
Are you the spouse, son, or daughter of an individual who has NO
committed or conspired to commit a human trafficking offense in
the United States or outside the United States and have you 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
NO
human trafficking offense in the United States or outside the
United States?
Do you seek to engage in espionage, sabotage, export control
NO
violations, or any other illegal activity while in the United States?
Do you seek to engage in terrorist activities while in the United
NO
States or have you ever engaged in terrorist activities?
Have you ever or do you intend to provide financial assistance or
NO
other support to terrorists or terrorist organizations?
Are you a member or representative of a terrorist organization? NO
Have you ever ordered, incited, committed, assisted, or otherwise
NO
participated in genocide?
Have you ever committed, ordered, incited, assisted, or otherwise
NO
participated in torture?
Have you committed, ordered, incited, assisted, or otherwise
participated in extrajudicial killings, political killings, or other acts NO
of violence?
Have you ever engaged in the recruitment or the use of the child
NO
soldiers?
Have you, while serving as a government official, been responsible
for or directly carried out, at any time, particularly severe NO
violations of religious freedom?
Have you ever been directly involved in the establishment or
enforcement of the population controls forcing a woman to
NO
undergo an abortion against her free choice or a man or a woman
to undergo sterilization against his or her free will?
Have you ever been directly involved in the coercive
NO
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 States
NO
immigration benefit by fraud or willful misrepresentation or other
unlawful means?
Have you ever withheld custody of a U.S. citizen child outside the
NO
United States from a person granted legal custody by a U.S. court?
Have you voted in the United States in violation of any law or
NO
regulation?
Have you ever renounced United States citizenship for the purpose
NO
of avoiding taxation?
Location Information
Location where you will be submitting your application
Current Location: Benin, NIGERIA
Preparer of Application
Did anyone assist you in
NO
filling out this application?
Your Personal Copy -- Do Not Bring to
Interview
You electronically signed your application on 31-May-2014 08:09:52. You were required to electronically sign your
application yourself, unless otherwise exempt by regulation, even if the application was prepared by someone other than
yourself. Your electronic signature certifies that you have read and understood the questions in this application and that
your answers are true and correct to the best of your knowledge and belief. The submission of an application containing
any false or misleading statements may result in the permanent refusal of a visa or the denial of entry into the United
States. All declarations made in this application are unsworn declarations made under penalty of perjury. (28 U.S.C. 1746).
The information that you have provided in your application and other information submitted with your application may be
accessible to other government agencies having statutory or other lawful authority to use such information, including for
law enforcement and immigration law enforcement purposes. The photograph that you provide with your application may
be used for employment verification or other U.S. law purposes.
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