Consular Electronic Application Center - Print Application +hitps: '/ceac state, gov/GENNTV/common’printapplication aspx?OC82, oy) US. De Deeangy y PEST Next Nonimmigrant Visa Application Application - Sensitive But Unclassified(SBU) Photo Provided: ‘ 3 “SAITO om DoeovVGscy lof3 05.09.2010 13:22Consular Electronic Application Center - Print Application +hitps: '/ceac state, gov/GENNTV/common’printapplication aspx?OC82, Personal, Address, Phone, and Passport Information Name Provided: Fall Name in Native Language Other Hames Used Sex Marital status: Date of Bith Place of Birth Nationality Other Nationalities: National Identifiation Number US. Social Security Number USS. Taxpayer 1D 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 Bock Number: CCountry/uthorty that Iesved Passport City Where Tseued Country Where Issued Issuance Date: Expiration Date Have you ever lost a passport or hag one stolen? Travel Information Prinelpal Applicant? A. | Purpose of Your Tip to US. Purpose (1) Intended Date of Amval: Intended Length of Stay in U.S. Address where you will stay in the U.S: Person/Entity Paying for Your Tap: ‘A. |other Persons Traveling with You: ‘Are you traveling as part of a group or organization? Persons Traveling with You: Name (3) Relationship to You: Have you ever been in the U.S? Have you ever been issued a U.S. visa? Have you ever been refused a U.S. Visa, been refused ‘admission to the United States, or withdrawn your pplication for admission at the point of entry? U.S. Contact Information Contact Person Name in the U.S. Organization ame in the US. Relationship to You USS. Contact Address Phone Number: Email Address Family Information Fathers Sumames Father's Given Names: Father's Date of Birth Is your father in the U.S.? Mother's Surnames Mother's Given Names: Mather’ ate of Birth: Is your mather in the U.S? Do you have any immediate relatives, not including parents inthe US? Do you have any other relatives in the United States? Spouse's Full Name: TIRDEA , LIDIA THRDEA LIDIA No. FEMALE MARRIED 26 JUNE 1985 TATARESTI , STRASENT , MOLDOVA MOLDOVA NO. 2000033024075 DOES NOT APPLY DOES NOT APPLY TATARESTI TATARESTI ‘STRASENT DOES NOT APPLY MOLDOVA ves. 23766428 29723065 DOES NOT APPLY 68328243, lonvatamanu@yahoo.com 80778380 DOES NOT APPLY MOLDOVA ‘CHSINAU MOLDOVA 19 AUGUST 2010 19 AUGUST 2020 No. ves ‘TOURIST/PERSONAL TRAVEL VISITOR (62) 15 NOVEMBER 2010 2 NONTH(S) 5979 DEVECCHI AVE #22 ‘SACRAMENTO, CALIFORNIA 95623 SEF ves No. TIRDEA,, ION SPOUSE No. No. No. NATALLIA, PAZNIAKOVICH DO NOT KNOW FRIEND 5979 DEVECCHI AVE #22 ‘SACRAMENTO, CALIFORNIA 95621 (216)339-2627 DOES NOT APPLY TROIAN oN 29 SEPTEMBER 1995 No. TROIAN WwUA 15 JULY 1942 No No. No. TIRDEA , 108 05.09.2010 1Consular Electronic Application Center - Print Application ‘hitps: //ceac state, gov/GENNIV/commonyprintapplication aspx?OC82. 3 of 3 05.09.2010 13:22