Personal, Address, Phone, and Passport Information

1. Name Provided: -------------------------------------------

2. Full Name in Native Alphabet: --------------------------------------------

3. Other Names Used: --------------------------------------------

4. Telecode Name Used: --------------------------------------------

5. Sex: -------------------------------------------

6. Marital Status: ------------------------------------------

7. Date of Birth: -------------------------------------------

8. Country/Region of Birth: --------------------------------------------

9. Country/Region of Origin (Nationality): --------------------------------------------

10. Do you hold or have you held any nationality --------------------------------------------

other than the one indicated above on nationality? -------------------------------------------

11. Are you a permanent resident of a country/region --------------------------------------------

other than your country/region of origin (nationality)

above?

12. National Identification Number: ------------------------------------------

13. U.S. Social Security Number: ------------------------------------------

14. U.S. Taxpayer ID Number: -------------------------------------------

15. Home Address: --------------------------------------------

16. City: -------------------------------------------

17. State/Province: -------------------------------------------

18. Postal Zone/ZIP Code: -------------------------------------------

19. Country/Region: --------------------------------------------

20. Same Mailing Address? --------------------------------------------

21. Primary Phone Number: --------------------------------------------

22. Secondary Phone Number: --------------------------------------------

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 23. Work Phone Number: --------------------------------------------

24. Have you used additional phone numbers --------------------------------------------

in the last five years?

25. Email Address: --------------------------------------------

26. Have you used additional email addresses in --------------------------------------------

the last five years?

27. Do you have a social media presence? --------------------------------------------

28. Social Media Provider/Platform (1): ------------------------------------------

29. Social Media Identifier: --------------------------------------------

30. Have you used additional social media --------------------------------------------

platforms in the last five years?

31. Passport/Travel Document Type: --------------------------------------------

32. Passport/Travel Document Number: -------------------------------------------

33. Passport Book Number: --------------------------------------------

34. Country/Authority that Issued Passport/Travel --------------------------------------------

35. City where issued: --------------------------------------------

36. State/Province where issued: --------------------------------------------

37. Country/Region where issued: --------------------------------------------

38. Issuance Date: --------------------------------------------

39. Expiration Date: --------------------------------------------

40. Have you ever lost a passport or had one stolen? --------------------------------------------

Travel Information
The List of Purposes of Trip to the U.S.

1.Purpose of Trip to the U.S. (1): --------------------------------------------

2. Specify:

3. Have you made specific travel plans? --------------------------------------------

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Provide a complete itinerary for your travel to the U.S.

4. Date of Arrival in U.S.: --------------------------------------------

5. Arrival Flight: --------------------------------------------

6. Arrival City: --------------------------------------------

7. Date of Departure from U.S.: -------------------------------------------

8. Departure Flight: --------------------------------------------

9. Departure City: --------------------------------------------

10. The Location(s) you plan to visit in the U.S. --------------------------------------------

11. Location (1):

Location (2):

Location (3):

Location (4):

12. Address where you will stay in the U.S.: --------------------------------------------

13. City, State --------------------------------------------

14. Postal / Zip Code --------------------------------------------

15. Person/Entity Paying for Your Trip: --------------------------------------------

16. Name of Person Paying for Your Trip: --------------------------------------------

17. Telephone Number: --------------------------------------------

18. Email Address: --------------------------------------------

19. Relationship to You: --------------------------------------------

20. Is the address of the party paying for your trip --------------------------------------------

the same as your Home or Mailing Address?

21. Other Persons Traveling with You: --------------------------------------------

22. Are you traveling as part of a group or organization? --------------------------------------------

23. Name of group: --------------------------------------------

24. Have you ever been in the U.S.? --------------------------------------------

25. Date Arrived (1): --------------------------------------------

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26. Length of Stay: --------------------------------------------

27. Do you or did you ever hold a U.S. Driver's License? --------------------------------------------

28. Have you ever been issued a U.S. Visa? --------------------------------------------

29. Date Last Visa was Issued: --------------------------------------------

30. Visa Number: --------------------------------------------

31. Are you applying for the same type of visa? --------------------------------------------

32. Are you applying in the same country or location --------------------------------------------

where the visa above was issued, and is this country

33. Have you been ten-printed? --------------------------------------------

34. Has your U.S. Visa ever been lost or stolen? --------------------------------------------

35. Has your U.S. Visa ever been cancelled or revoked? ------------------------------------------

41. 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?

42. Has anyone ever filed an immigrant petition on --------------------------------------------

your behalf with the United States Citizenship and

Immigration Services?

U.S. Contact Information

2.Organization Name in the U.S.: -----------------------------------------------

3.Relationship to You: -----------------------------------------------

4.U.S. Contact Address: -----------------------------------------------

5.Phone Number: -----------------------------------------------

6.Email Address: -----------------------------------------------

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Family Information
1. Father's Surnames: ----------------------------------------------

2. Father's Given Names: ----------------------------------------------

3. Father's Date of Birth: ----------------------------------------------

4. Is your father in the U.S.? ----------------------------------------------

5. Mother's Surnames: ----------------------------------------------

6. Mother's Given Names: ----------------------------------------------

7. Mother's Date of Birth: ----------------------------------------------

8. Is your mother in the U.S.? ----------------------------------------------

9. Do you have any immediate relatives, not ----------------------------------------------

including parents in the U.S.?

10. Do you have any other relatives in the United States? ----------------------------------------------

Spouse Information
1. Spouse’s Name -----------------------------------------------

2. Spouse’s Date of birth -----------------------------------------------

3. Spouse’s Place of birth -----------------------------------------------

4. Spouse’s Phone Number -----------------------------------------------

5. Spouse’s Email Address -----------------------------------------------

Work / Education / Training Information

2. Present Employer or School Name: -----------------------------------------------

3. Present Employer or School Address: -----------------------------------------------

4. City: -----------------------------------------------

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5. State/Province: -----------------------------------------------

6. Postal Zone/Zip Code: -----------------------------------------------

7. Country/Region: -----------------------------------------------

8. Start Date: -----------------------------------------------

9. Work Phone Number: -----------------------------------------------

10. Monthly Salary in Local Currency (if employed): -----------------------------------------------

11. Briefly Describe your Duties: -----------------------------------------------

12. Were you previously employed? -----------------------------------------------

13.Previous Occupation: -----------------------------------------------

14. Previous Employer or School Name: -----------------------------------------------

15. Previous Employer or School Address: -----------------------------------------------

16. City: -----------------------------------------------

17. State/Province: -----------------------------------------------

18. Postal Zone/Zip Code: -----------------------------------------------

19. Country/Region: -----------------------------------------------

20. Job Title: -----------------------------------------------

21. Supervisor Name

22. Start / End Date: -----------------------------------------------

23. Work Phone Number: -----------------------------------------------

24. Briefly Describe your Duties: -------------------------------------------------------------

22. Have you attended any educational institutions -----------------------------------------------

at a secondary level or above?

23. Name of Institution (1): -----------------------------------------------

24. Address of Institution: -----------------------------------------------

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25. City: ------------------------------------------------

26. State/Province: -----------------------------------------------

27. Postal Zone/ZIP Code: -----------------------------------------------

28. Country/Region: -----------------------------------------------

29. Course of Study: -----------------------------------------------

30. Date of Attendance From: -----------------------------------------------

31. Date of Attendance To: -----------------------------------------------

32. Do you belong to a clan or tribe? -----------------------------------------------

Provide a List of Languages You Speak:

33. Language Name (1): -----------------------------------------------

34. Have you traveled to any countries/regions -----------------------------------------------

within the last five years?

Provide a List of Countries/Regions Visited

35. Country/Region (1): -----------------------------------------------

36. Country/Region 2): -----------------------------------------------

37. Have you belonged to, contributed to, or worked -----------------------------------------------

for any professional, social, or charitable organization?

38. Do you have any specialized skills or training, such -----------------------------------------------

as firearms, explosives, nuclear, biological, or

chemical experience?

39. Have you ever served in the military? -----------------------------------------------

40. Have you ever served in, been a member of, or been -----------------------------------------------

involved with a paramilitary unit, vigilante unit,

rebel group, guerrilla group, or insurgent organization?

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Student/Exchange Visa Information (Student Only)
Additional Point of Contact Information:

1.Name (1): -----------------------------------------------

2. Street Address: -----------------------------------------------

3. City: -----------------------------------------------

4. State/Province: -----------------------------------------------

5. Postal Zone/ZIP Code: -----------------------------------------------

6. Country/Region: -----------------------------------------------

7. Telephone Number: -----------------------------------------------

8. Email Address: -----------------------------------------------

9. Name (2): -----------------------------------------------

10. Street Address: -----------------------------------------------

11. City: -----------------------------------------------

12. State/Province: -----------------------------------------------

13. Postal Zone/ZIP Code: -----------------------------------------------

14. Country/Region: -----------------------------------------------

15. Telephone Number: -----------------------------------------------

16. Email Address: -----------------------------------------------

18. SEVIS ID: -----------------------------------------------

19. Name of School: -----------------------------------------------

20. Course of Study: -----------------------------------------------

21. Street Address: -----------------------------------------------

Location Information
Location where you will be Submitting your application? -----------------------------------------------
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