REMINDER: USE CAPITAL LETTERS

NO ABBREVIATION & WRITE LEGIBLE

US VISA REQUIREMENTS US EMBASSY APPLICATION
Please provide the following upon submission of PACIFIC OCEAN MANNING, INC./NORTHSEA MARINE
application KESTREL SHIPPING INC.
Photocopy of new passport/New SIRB/ Old

USA Visa/ RCBC receipt
3pc 2x2 picture white background-

“MATT paper” Received by: _______________
NOTE: DEPOSIT SLIP attached at the back of DATE: ____________________
application - Visa payment RCBC/any branch-

bring valid photocopy passport.

Vessel Name _______________________________ Crew Managers Name:_______________________

Position ___________________________________ Basic Salary ________________ _______________

DATE HIRED:_______________________________

PERSONAL, ADDRESS, PHONE and PASSPORT DETAILS:

Surname: _________________ First name: _________________ Middle Name: _________________

Marital Status: _______________________________ Gender: _______________________________

Date of Birth: Day: ___________ Month: ____________ Year: ___________

Place of Birth: _________________________________________________________________________

Email Address & Social Media Username (Ex: Facebook, Twitter, Youtube, LinkedIn, & Instagram):
_______________________________________________________________________________________

Home Address: ________________________________________________________________________

_________________________________________________Postal Zone/Zip Code:__________________

Home Phone Number: __________________________________________________________________

Cell Phone Number: ______________________________________________________________

PASSPORT NUMBER: _________________________

Country/Authority that Issued Passport: ____________________________________________________

City Where Issued: _____________________________________________________________________

Country Where Issued: __________________________________________________________________

Issuance Date: __________________ Expiration Date: __________________________

SEAMAN’S BOOK NUMBER: __________________________________________________________

Country/Authority that Issued: ____________________________________________________

City Where Issued: _____________________________________________________________________

Issuance Date: ___________________ Expiration Date: __________________________

Have you ever lost a passport or had one stolen: ___________ YEAR LOST: ______________

Reason _____________________________________________________________________________

Have you ever lost USA Visa : ___________ DATE ISSUE: DAY:_____ MONTH: ____ YEAR: ____

Reason _____________________________________________________________________________

Travel Information

Have you ever been in the U.S / Previous U.S. Visits in the last 10 years?

(Reference: old passport/seaman’s book/shore pass-landing permit)

1. D: ___________ M: ____________ Y: ___________ LENGTH OF STAY: ________________
2. D: ___________ M: ____________ Y: ___________ LENGTH OF STAY: ________________
3. D: ___________ M: ____________ Y: ___________ LENGTH OF STAY: ________________
4. D: ___________ M: ____________ Y: ___________ LENGTH OF STAY: ________________
5. D: ___________ M: ____________ Y: ___________ LENGTH OF STAY: ________________

Have you ever been issued U.S. Visa: D: ____ M: ____ Y: ___ _ REF NO: __________ in red number (right side).

IF ISSUED J1 VISA? D: ________ M:_______ Y:_______ U.S SOCIAL SECURITY NUMBER: __________

Have you ever been REFUSED/DENIED U.S. Visa: D: ____M: ____ Y: ____ REF NO: __________

Reason for Denial _____________________________________________________________________

Family Information

Father’s Surname: ______________ First name: ________________ Middle Name: ________________

Father’s date of Birth: D: ___________ M: ____________ Y: ___________

Mother’s Maiden Name

Surname: ______________ First name: ________________ Middle Name: ________________
Mother’s date of Birth: D: ___________ M: ____________ Y: ___________

Do you have any other relatives in the U.S.: _________________________________________________

Surname: First name: Middle Name: RELATION TO YOU:

1. _________________ _________________ _________________ _________________
2. _________________ _________________ _________________ _________________
3. _________________ _________________ _________________ _________________
4. _________________ _________________ _________________ _________________

Encircle the following STATUS – (US CITIZEN , US LEGAL PERMANET RES., NON- IMMIGRANT)

HAS ANY ONE EVER FILED AN IMMIGRANT PETITION ON YOUR BEHALF? YES:_____ NO:_____
REASON:_____________________________________________________________________________

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Spouse’s Surname : ______________ First name: ________________ Middle Name: ________________

Spouse’s Date of Birth: D: ___________ M: ____________ Y: ___________

Spouse’s City of Birth: ___________________________________________________________________

Work / Education / Training Information

CREW Previous Employer Name: _____________________________________________________________

Position: _____________________________________________________________________________

Employer Address: _____________________________________________________________________

Telephone Number: ____________________________________________________________________

Supervisor’s Name: _____________________________________________________________________

Employment Date From: ________________ To: ____________________

(first vessel sign on) dd/mm/yy (last vessel sign off) dd/mm/yy

Briefly Describe Your Duties: _____________________________________________________________

Have You Attended Any Educational Institution: (College /Secondary ):

Name of School _______________________________________________________________________

Address of School: _____________________________________________________________________

Course of Study: _______________________________________________________________________

Date of Attendance From: ___________________ To: ____________________

(day/month/year) (day/month/year)

Have you travelled to any countries w/in the last 5 years:

Country Visited (1): ______________________ Country Visited (6): ________________________

Country Visited (2): _______________________ Country Visited (7): _______________________

Country Visited (3): _______________________ Country Visited (8): _______________________

Country Visited (4): _______________________ Country Visited (9): _______________________

Country Visited (5): _______________________ Country Visited (10): ______________________

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SECURITY BACKGROUND INFORMATION Yes No

1. Are you or have you ever been a drug abuser or addict ?

2. Have you ever been arrested or convicted for any offense or crime, even
Though subject of a pardon, amnesty or other similar action.
3. Have you ever been arrested or convicted for any offense or crime, even
Though subject of a pardon, amnesty or other similar action.
4. Have you ever violated, or engaged in a conspiracy to violate, any law
Relating to controlled substances?
5. Have you ever been involved in, or do you seek to engage in, money
Laundering?
6. Have you ever been committed or conspired to commit a human trafficking
Offense in the United States or outside the United States.
7. Do you seek engage in espionage, sabotage, export control violations, or any other
Illegal activity while in the United States?
8. Do you seek to engage in terrorist activities while in the United States or have you
Ever engaged in terrorist activities?
9. Do you have a communicable disease of public health significance include
(chancroid, gonorrhea, granuloma, infectious leprosy, lymphogranuloma venereum,
Infectious stage syphilis, active tuberculosis and other diseases as determined by the
Department of Health and Human Services ).

REMINDER- please inform if reimbursement for US Visa will be process on his/her first
allotment.

FOR NORTHSEA CREW:

DETAILS FOR REIMBURSEMENT!!!!
ACCOUNT NAME:______________________________________

ACCOUNT NUMBER:_____________________________________

VESSEL NAME:____________________________________________

BRANCH: (BPI/BDO, PESO ACCOUNT only)_______________________________________