Full Name in Native Language *
Other Names Used *
Telecode Names Used *
Sex *
Marital Status
Date of Birth
Place of Birth
Nationality
Home address
City
State
Mailing address
Primary phone number
Secondary phone number
Work phone number
Email address
Passport/Travel Document type
Passport/Travel Document 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 (Yes/No)
Purpose of Your Trip to U.S
Specific
Have you made specific travel plans
Intended Date of Arrival
Intended Length of Stay in U.S
Address where you will stay in the U.S
Person/Entity Paying for Your Trip
Are there other persons travelling with you?
Are you travelling as part of a group or organisation?
Have you ever been in the U.S?
Have you ever been issued a U.S. visa? YES/NO If YES, When: DATE, MONTH YEAR, Location, And TYPE OF VISA ISSUED
Have you ever been refused a U.S. Visa, been refused admission to the United States, or withdrawn your application for admission at the point of entry?
If YES, When: DATE, MONTH YEAR: Location, TYPE of VISA APPLIED FOR, Explain why you were refuse
Has anyone ever filed an immigration petition on your behalf with the United States citizenship and immigration services?
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 surname
Father’s given names
Father’s Date of Birth
Is your father in the U.S.? YES/NO
Mother’s Names
Mother’s Given name
Mother’s Date of Birth
Is your mother in the U.S? (Yes/No)
Do you have any immediate relatives, not including parents in the U.S.? {Yes/No)
Spouse’s full name
Spouse’s date of birth
Spouse’s country/region (Nationality)
Spouse address
Primary Occupation
Specify
Present Employer or School Name
Work Address
State/province
Postal zone/zip code
Country/Region
Month Salary in Local Currency (If employed)
Briefly Describe your Duties
Were you previously employed
Have you attended any educational institutions at a secondary level or above
Name of Institution
Address of Institution
State/Province
Postal Zone/ZIP Code
Course of Study
Date of attendance from
Date of attendance to
Do you belong to a clan or tribe
Provide a list of Languages you speak
Have you travelled to any countries within the last five years
If yes state countries/region visited
Have you belonged to, contributed to, or worked for any professional, social or charitable organisation
Do you have any specialized skills or training, including firearms, explosives, nuclear, biological, or chemical experience? (Yes/No)
Have you ever served in the military? (Yes/No)
