Personal, Address, Phone, and Passport Information

Sur Name Provided: …………………………………………………………………………………….

Given name …………………………………………………………………………………….

Sex: …………………………………………………………………………………….
Marital Status:
…………………………………………………………………………………….
Date of Birth: …………………………………………………………………………………….
Place of Birth: …………………………………………………………………………………….
Nationality: …………………………………………………………………………………….

Other Nationalities of another country ………:

…………………………………………………………………
National Identification Number:
……………………………………………………………………………………

Home Address:
……………………………………………………………………………………………..
City: …………………………………………………………………………………………….
State/Province:
…………………………………………………………………………………………….
Postal Zone/ZIP Code:
…………………………………………………………………………………………….
Country:
…………………………………………………………………………………………….

Same Mailing Address?

……………………………………………………………………………………………
Home Phone Number: ……………………………………………………………………………………………
Work Phone Number: ………………………………………………………………………………………………
Work Fax Number: ……………………………………………………………………………………
Mobile/Cell Phone Number: …………………………………………………………………………………….
Email Address:
…………………………………………………………………………………….

Passport Number:…………………………………………………………………………
Passport Book Number: …………………………………………………………………………………….
Country/Authority that Issued
Passport………………………………………………………………………………...
City Where Issued: …………………………………………………………………………………….
State/Province Where Issued:
…………………………………………………………………………………….
Country Where Issued:
…………………………………………………………………………………….
Issuance Date:
…………………………………………………………………………………….
Expiration Date:
…………………………………………………………………………………….

Have you ever lost a passport or had one stolen? If yes

Passport Number (1): ………………………………………………………………………….
Country/Authority that Issued Passport:
………………………………………………………………………….
 Are you the Principal Applicant? ………………………………………………….
………………………
▼ Purpose of Your Trip to U.S.
……………………………………………………………………………
Purpose (1) : ……………………………………………………………………………

Specific Travel Plan? ………………………………………………………………………………

Date of Arrival in U.S.:
………………………………………………………………………………
Arrival Flight: ………………………………………………………………………………
Arrival City: ………………………………………………………………………………
Date of Departure from U.S ……………………………………………………………………………….
Departure Flight:
………………………………………………………………………………
Departure City:
………………………………………………………………………………
▼ The Location you plan to visit in the U.S.
………………………………………………………………………………
Location (1): ………………………………………………………………………………
Address where you will stay in the U.S.:
……………………………………………………………………………….

Person/Entity Paying for Your Trip: ……………………………………………………………

Name of Person Paying for Your Trip: ……………………………………………………………
Telephone: ……………………………………………………………
Email Address: ……………………………………………………………
Relationship to You: ……………………………………………………………
Is the address of the party paying for your ……………………………………………………………
trip the same as your Home or Mailing ……………………………………………………………

Is the address of the party paying for your trip the same as your Home or Mailing Address?
Payer Address: ……………………………………………………………
City: ……………………………………………………………
State/Province: ……………………………………………………………

Postal Zone/ZIP Code: ……………………………………………………………

Country: ……………………………………………………………

Other Persons Traveling with You: ……………………………………………………………

Are you traveling as part of a group or organization?
……………………………………………………………
Persons Traveling with You: …………………………………………………………..
Name (1) : ……………………………………………………………
Relationship to You: ……………………………………………………………

Have you ever been in the U.S.? ……………………………………………………………

Provide information on your last five U.S. visits: ……………………………………………………………

Travel Date of Arrival(date, month, year) ……………………………………………………………

Length of Stay: ……………………………………………………………

Do you or did you hold a U.S. Driver's License? ……………………………………………………………

Have you ever been issued a U.S. Visa? ……………………………………………………………
Date Last Visa was Issued: (date, month, year) ……………………………………………………………
Visa Number: ……………………………………………………………
Are you applying for the same type of visa?
……………………………………………………………..
Are you applying in the same country where the visa above is issued and is this country your
principal country of residence?
Have you been ten-printed? ……………………………………………………………
Has your U.S. Visa ever been lost or stolen?
……………………………………………………………
Year visa was lost or stolen: ……………………………………………………………
Has your U.S. Visa ever been cancelled or revoked?
……………………………………………………………
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?
Explain: ……………………………………………………………

Contact Person Name in the U.S.: ……………………………………………………………

Organization Name in the U.S.: ……………………………………………………………
Relationship to You ……………………………………………………………
U.S. Contact Address: ……………………………………………………………
Phone Number: ……………………………………………………………
Email Address: ……………………………………………………………

Father's Surnames: ……………………………………………………………

Father's Given Names: ……………………………………………………………
Father's Date of Birth: ……………………………………………………………
Is your father in the U.S.? ……………………………………………………………
Mother's Surnames: ……………………………………………………………
Mother's Given Names: ……………………………………………………………
Mother's Date of Birth: ……………………………………………………………
Is your mother in the U.S.? ……………………………………………………………

Do you have any immediate relatives, not including parents in the U.S.?
Relative Name (1): ……………………………………………………………
Relationship to you: ……………………………………………………………
Status: if it is a US CITIZEN

Spouse's Full Name: ……………………………………………………………

Spouse's Date of Birth: ……………………………………………………………
Spouse's Nationality: ……………………………………………………………

Spouse's City of Birth: ……………………………………………………………

Spouse's Country of Birth: ……………………………………………………………
Spouse’s Address: ……………………………………………………………

Primary Occupation: ……………………………………………………………

Present Employer or School Name: ……………………………………………………………
Address: ……………………………………………………………
City: ……………………………………………………………
State/Province: ……………………………………………………………
Postal Zone/Zip Code: ……………………………………………………………
Country: ……………………………………………………………
Monthly Salary in Local Currency (if employed): ……………………………………………………………

When did you start working, day , month and year. Compulsory

Briefly Describe your Duties: ……………………………………………………………

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Were you previously employed? ……………………………………………………………
Employer Name (1): ……………………………………………………………
Employer Address: ……………………………………………………………
City: ……………………………………………………………
State/Province: ……………………………………………………………
Postal Zone/Zip Code: ……………………………………………………………
Country: ……………………………………………………………
Telephone Number: ……………………………………………………………
Job Title: ……………………………………………………………
Supervisor's Name: ……………………………………………………………
Employment Date From: ……………………………………………………………
Employment Date To: ……………………………………………………………
Briefly describe your duties: ……………………………………………………………

Have you attended any educational institutions other than elementary schools?
Name of Institution (1): ……………………………………………………………
Address of Institution: ……………………………………………………………
City: ……………………………………………………………
State/Province: ……………………………………………………………

Postal Zone/ZIP Code: ……………………………………………………………

Country:
Course of Study: ……………………………………………………………
Date of Attendance From: ……………………………………………………………
Date of Attendance To: ……………………………………………………………
Do you belong to a clan or tribe?
Have you traveled to any countries within the last five years?
Country Visited (1):

Have you belonged to, contributed to, or worked for any

professional, social, or charitable organization?
Do you have any specialized skills or training, including firearms,
explosives, nuclear, biological, or chemical experience?
Explain:

Have you ever served in the military?

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?