Kindly read the form and then fill with neatly.

PERSONAL INFORMATION 1 Answer

Surname (Enter your surname as per your passport)
Given names (Enter first & middle names as per
passport)
Full name in Native Alphabet (Click 'Does Not Apply'
button)
Have you ever used other names (Complete if
applicable OR choose 'NO')

Sex (Choose Male OR Female)

Marital Status (Choose one from drop down list)

Date of Birth (Enter DOB as per passport)

Place of Birth (Enter as per passport)

State/Province of Birth (Click Does Not Apply button)

Country of Birth (Choose Country from drop down
list)
PERSONAL INFORMATION 2

Nationality (Choose from drop down list)

Do you hold other Nationality (Choose YES or NO as
applicable)
National Identification Number (Click Does Not
Apply' button)
US Social Security Number (Click Does Not Apply'
button)
US Taxpayer ID Number (Click Does Not Apply'
button)
Click Next: Address and Phone

Home Address (Please Enter)

State/Province

Postal Zonal Zip Code

Country.

Mailing Address.

Home Phone.

Work Phone.

Work Fax Number.

Mobile/Cell phone number.

Email address. ( Mandatory )

Click Next: Passport
Passport Number:
Type of travel document:
(Regular,Diplomatic,Other)
Country/Authority that issued Passport (Please Enter
e. g. Ireland)

Where was Passport issued

State/Province

Country

Issuance Date of passport.

Expiration Date of passport.

Have you ever lost/stolen

Click Next: Travel

Are you the principal applicant (Choose
Yes/No)Answer the additional question: Surnames of
Principal Applicant Given Names of Principal
Applicant Principal Applicant's Purpose of Trip to U.S.
Purpose of Trip to USA.

Intended Date of arrival in US.

Intended length of stay in US.

Address where you will stay in US (If you don't have
an address please enter CIEE's address (your US
Sponsor) below or any intended hotel address with
pincode and telephone no.

Street Address Line 1

Street Address Line 2

City

State

Zip Code
Person/Entity paying for your trip.(If not self or other
person or company mention name, contact no, email
id, relationship & address)

Click Next: Travel Companions

Are there other persons traveling with you? If not
traveling with family members, choose NO Enter
person(s) traveling with youSurnames of Person
Traveling With You, Given Names of Person
Traveling With You, Relationship with Person.
Click Next: Previous US Travel
Have you ever been in the USA Choose YES or NO as
applicable (if yes, Provide information on your last
five U.S. visits:Date of Arrival (dd/mm/year),Length
of stay.
Have you ever been issued a US Visa Choose YES or
NO as applicable (if yes, enter details as requested
Previous U.S. VisasDate Last Visa Was Issued, Visa
Number) Are you applying for the same type of visa?
Are you applying in the same country where the visa
above was 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?
Has your U.S. Visa ever been cancelled or revoked?
(If yes then explain)
Have you ever been refused a US Visa? Choose YES
or NO as applicable (if yes, enter details as
DD/MM/Year, visa category of rejection and from
which place applied)

Has anyone ever filed an immigrant petition on your

behalf with the united states citizenship &
Immigration Services? (if yes then explain)
Click Next: US Contact

Contact Person (Leave Blank unless known)

Given Names.

Organization Name (Enter CIEE your US Sponsor)

Relationship to You.

Address with pincode& Phone of Contact (If you

don't have an address please enter CIEE's address
(your US Sponsor) below)

Street Address Line I

Street Address Line 2

City (Portland)

State (Maine)

Zip Code

Phone Numbers

Email Address
Click Next: Family
Fathers Full Name with date of birth.

Mothers Full Name with date of birth.

Do you have any immediate relatives in USA.

(Choose YES or NO as applicable) Means
fiancé/fiancée, spouse (husband/wife), child
(son/daughter), or sibling (brother/sister).Also
mention visa type.
Do you have any other relatives in USA? Choose YES
or NO as applicable) If yes then Provide the following
information:Surnames,Given Names, Relationship to
you, Relative's status .i.e. citizen, work visa etc.
Family Information: Spouse NOTE: Enter current
spouse information. If divorced, enter previous
spouse information.Spouse's Surnames, Spouse's
Given Names,Spouse's Date of Birth,Spouse's
Nationality,Spouse's Place of Birth (City and
country)Spouse's Address
Click Next: Work/Education/Training
Primary Occupation.

Present Employer or School Name.

Present employer or School address with pincode
and contact number (Enter details as applicable)

Monthly Salary Choose (if employed) Joining Date

Briefly describe your duties with designation Enter
(please provide the details)
Click Next: Additional Work/Education/Training
Information
Were you previously employed (provide details)
Employer/Employment Information:Employer
Name,Employer Address with contact no, Superior
full name, designation in that company,
joining/releaving dates (DD/MM/Year)

Have you attended any educational institutions

other than elementary school?

Name of institution:

Address of institution, city, state/province, country,

course of study, date of attendance from, date of
attendance to:

Have you traveled to any countries within the last

five years? (Mention countries name)

Do you belong to a clan or tribe?

Provide a list of Language you Known?

Click Next: Security and Background

Medical & Health Information (Please answer all 3
questions TRUTHFULLY)
1)Do you have a communicable disease of public
health significance such as tuberculosis (TB)?
2) Do you have a mental or physical disorder that
poses or is likely to pose a threat to the safety or
welfare of yourself or others?
3) Are you or have you ever been a drug abuser or
addict?
Click Next: Criminal
Criminal Information (Please answer all 4 questions
TRUTHFULLY)
1) Have you ever been arrested or convicted for any
offense or crime, even though subject of a pardon,
amnesty, or other similar action?
2) Have you ever violated, or engaged in a
conspiracy to violate, any law relating to controlled
substances?
3) Are you coming to the United States to engage in
prostitution or unlawful commercialized vice or have
you been engaged in prostitution or procuring
prostitutes within the past 10 years?
4) Have you ever been involved in, or do you seek to
engage in, money laundering?NO
Click Next: Security
Security Information
1) Do you seek to engage in espionage, sabotage,
export control violations, or any other illegal activity
while in the United States?
2) Do you seek to engage in terrorist activities while
in the United States or have you ever engaged in
terrorist activities?
3) Have you ever or do you intend to provide
financial assistance or other support to terrorists or
terrorist organizations?
4) Are you a member or representative of a terrorist
organization?
5) Have you ever ordered, incited, committed,
assisted, or otherwise participated in genocide?
6) Have you committed, ordered, incited, assisted,
or otherwise participated in extrajudicial killings,
political killings, or other acts of violence?
7) Have you, while serving as a government official,
been responsible for or directly carried out, at any
time, particularly severe violations of religious
freedom?
Click Next: Immigration Law Violations
Immigration Law Violations (Please answer the
question TRUTHFULLY) Have you ever sought to
obtain or assist others to obtain a visa, entry into the
United States, or any other United States
immigration benefit by fraud or willful
misrepresentation or other unlawful means?
Click Next: Miscellaneous
Miscellaneous Information (Please answer all 3
questions TRUTHFULLY)
1) Have you ever withheld custody of a U.S. citizen
child outside the United States from a person
granted legal custody by a U.S. court?
2)Have you voted in the United States in violation of
any law or regulation?
3) Have you ever renounced United States
citizenship for the purpose of avoiding taxation?