US VISA APPLICATION FORM

PERSONAL, ADDRESS, PHONE and PASSPORT INFORMATION

1) Name Provided:
Surname :_______________________

First Name:__________________________

2) Full Name in Native Language:______________________

3) Other Names Used:_______________________

4) Sex:____________________

5) Martial Status:_____________________

6) Date of Birth:________________________

7) Place of Birth:_______________________ State of Birth:_______________________________

8) Nationality:_______________________

9) Other Nationalities:____________________

10) National Identification Number: DOES NOT APPLY

11) U.S. Social Security Number: DOES NOT APPLY

12) U.S. Taxpayer ID Number: DOES NOT APPLY

13) Home Address:_____________________________________________

________________________________________________________

14) City:____________________________

15) State/Province:_______________________

16) Postal Zone/ ZIP Code:_____________________

17) Country:_________________________-

18) Same Mailing Address: YES

19) Home Phone Number:____________________________

20) Work Phone Number: 912267551700

21) Work Fax Number: 912267551771

22) Mobile/ Cell Phone Number: ___________________________

23) Email Address: ____________________________________

24) Passport Number: ______________________________

25) Passport Book Number:__Does Not Apply_________________________

26) Country/Authority that Issued Passport:_____________________

27) City Where Issued: ___________________________

28) Issuance Date: ___________________________

29) Expiration Date: __________________________

30) Have you ever lost a passport or had one stolen:_________________________

TRAVEL INFORMATION

1. Principal Applicant: YES

2. Purpose of Your Trip to U.S.

3. Purpose: OTHER
4. Other – Specify: SHIPPING

5. Intended Date of Arrival: Will be one month letter of your interview date.

6. Intended Length of Stay in U.S.: 1 DAY

7. Address where you will stay in U.S.: 4655 SWEETWATER BLVD

SUITE 650-SUGARLAND
HOUSTON
TEXAS
77479

8. Person/Entity Paying for your Trip: COMPANY

9. Name of Company/Organization Paying for

your trip: EXECUTIVE SHIP MANAGEMENT
SAI COMMERCIAL ANNEXEE
2ND FLOOR BKS DEVSHI MARG GOVANDI
MUMBAI
MAHARASHTRA
400088

10. Telephone: 912267551700

 11. Relationship to You: EMPLOYER

12. In the address of the party paying for your trip the same as your
13. Home or Mailing Address: YES

14. Other Persons Traveling with You:

15. Have you ever been in the U.S:
Dd-mm-yy ______________________

16. Previous last five U.S. visits (mention date)

Travel Date of Arrival:

Dd-mm-yy ______________________

17. Length of Stay:

18. Do you or did you hold a U.S. Driver’s License: NO

19. Have you ever been issued a U.S. Visa: ___________________

20. Date last Visa was Issued:__________________________

21. Visa Number:________________________

22. Are you applying for the same type of Visa:_________________

23. Are you applying in the same country where the visa above
Is issued and is this country your principal country of residence:__________

24. Have you been Ten-Printed: NO

25. Has your U.S. Visa ever been lost or stolen:____________________

26. Has your U.S. Visa ever been Cancelled or Revoked:_______________________-

27. Have you ever been refused a U.S. Visa, been refused admission to the
United States, or withdrawn your application for admission at the
Point of entry:__________________________

U.S. CONTACT INFORMATION

1. Contact Person Name in the U.S.: NAVAL, ARANKE

2. Organization Name in the U.S.: EXECUTIVE SHIPPING SERVICES

3. Relationship to You: OTHER

 4. U.S. Contact Address: 4655 SWEETWATER BLVD
SUITE 650-SUGARLAND
HOUSTON
TEXAS
77479

5. Phone Number: 281-265-2154

6. Email Address: DOES NOT APPLY

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?__________________________-

11. Spouse’s Full Name:________________________

12. Spouse’s Date of Birth:____________________

13. Spouse’s Nationality:_________________________

14) Spouse’s City of Birth:__________________________

14. Spouse’s Country of Birth:_____________________

15. Spouse’s Address:___________________________

WORK/ EDUCATION/ TRAINING INFORMATION:

1. Primary Occupation: OTHER

2. Specify Other: SHIPPING

3. Present Employer or School Name: EXECUTIVE SHIP MANAGEMENT

4. Address: SAI COMMERCIAL ANNEXEE

2 ND FLOOR BKS DEVSHI MARG GOVANDI
MUMBAI
MAHARASHTRA
400088

5. Month Salary in Local Currency: DOES NOT APPLY

6. Briefly describe your Duties: ________________________________

7. Where you previously employed? __________________ (Fill Information of Last company

before joining ESM)

8. Employer Name : ___________________________

9. Employer Address:___________________________

City : ________________________________

State/Province: ________________________________

Postal Zone/Zip Code:__________________________

Country:_________________________________

Telephone No:__________________________

Job Title:____________________________________

Supervisor’s Name:___________________________

Employment Date From:____________________dd-mm-yy

Employment Date To:_______________________dd-mm-yy

Briefly described your duties: _______________________________

10. Have you attended any educational institutions other than elementary schools? (STWC
Courses)
 I) Name of Institution:_____________________________________

Address of Institution:________________________________________

City :___________________________________

State/Province :___________________________________

Postal Zone/ZIP Code:_______________________________

Country :________________________________

Course of Study :________________________________

Date of Attendance From:______________________________

Date of Attendance To: __________________________________

ii) Name of Institution: _____________________________________

Address of Institution: ________________________________________

City : ___________________________________

State/Province : ___________________________________

Postal Zone/ZIP Code: _______________________________

Country : ________________________________

Course of Study : ________________________________

Date of Attendance From: ______________________________

Date of Attendance To: __________________________________

11. Have you traveled to any countries within the

last five years?__(Mention any four countries

recent)_____________________________________________

● List Of Languages That You Can Speak:

12. Have you belonged to , contributed to, or worked for any professional ,social,

Or charitable organization?__________________________
 13. Do you have any specialized skills or training, including firearms, explosives,

Nuclear , biological or chemical experience?________________________

14. Have you ever served in military? _____________________

Name of the country:_________________________

Branch of service:__________________________

Rank/Position:_____________________________

Military Speciality:________________________

Date of Service from:__________________dd-mm-yy

Date of Service to:_____________________dd-mm-yy

15. 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?__________________________

CREW VISA INFORMATION:

1. Specific job title aboard aircraft or vessel(RANK): __________________________

2. Name of company that owns the aircraft or

vessel you will be working on: EXECUTIVE SHIP MANAGEMENT

3. Company telephone no: 912267551700

4. Did you acquire your position using a recruiting/ manning/ crewing

Agency? NO

5. Seagoing Ship/Vessel Name :

6) Seagoing Ship/Vessel Identification No:

PHOTO SPECIFICATION:
1. 50 X50 MM
2. MATT FINISH
3. WHITE BACKGROUND
4. DARK SHIRT
5. 80% OF FACE SHOULD BE VISIBLE IN THE PHOTO