You are on page 1of 8

U.S.

VISA APPLICATION FORM QUESTIONNAIRE


SECURITY QUESTION: Please select one and place answer
What is the given name of your mother's mother? What is the given name of your father's father? What is your maternal grandmother's maiden name? What name did your family used to call you when you were a child? In what city did you meet your spouse/significant other? What is the name of your favorite childhood friend? What street did you live on when you were 8 years old? What is your oldest sibling's birthday month and year? What is the middle name of your youngest child? What is your oldest sibling's middle name? What school did you attend when you were 11 years old? What was your home phone number when you were a child? What is your oldest cousin's first and last name? What was the name of your favorite stuffed animal or toy? In what city or town did your mother and father meet? What was the last name of your favorite teacher? In what city does your nearest sibling live? What is your youngest sibling's birthday month and year? In what city or town was your first job? What was the name of your first boyfriend or girlfriend?

Personal, Address, Phone, and Passport information Name Provided: Surname(s) Given Names (please include Middle Name) Full name in Native language:(if applicable) Other Names Used: Sex: Marital Status: Date of Birth: City of Birth: State/Province of Birth: Country of Birth: Nationality: Other Nationalities: National Identification Number: U.S. Social Security Number: U.S. Taxpayer ID Number: Home Address:

No. & Street City: State/Province: Postal Zone/ZIP Code: Country: Same Mailing Address? IF NO No. & Street City: State/Province: Postal Zone/ZIP Code: Country: Home Phone Number: (Required) Work Phone Number: Work Fax Number: Mobile/Cell Phone Number: Email Address: Passport Number: Country/Authority that Issued passport: City Where Issued: Issuance Date: Expiration Date: Have you ever lost a passport or had one stolen? Travel Information Principal Applicant? Purpose of your Trip to U.S.: Intended Date of Arrival in the US: Arrival City: Intended Length of Stay in U.S.: Date of Departure from US: Departure City: Address where you will stay in the U.S.:

Person/Entity paying for Your Trip: IF OTHER PERSON Surname of person paying for trip Given Names of person paying for trip Telephone no.

Myself

Other person

Employer

Email Address: Relationship to You: IF EMPLOYER Name of Company/Organization Paying for Trip: Telephone: Relationship to You: Is the address of the party paying for your trip The same as your Home or Mailing Address? If NO Address of Company/Organization paying Other Persons Traveling with You: (1) (1) Relationship to You: Other Persons Traveling with You: (2) (2) Relationship to You: Are you traveling as part of a group or organization? Name of Group: Have you ever been in the U.S.? If Yes, please indicate: Previous U.S. Visits in the last 5 years: Travel Date of Arrival (1): (mm/dd/yyyy) Length of Stay: Travel Date of Arrival (2): (mm/dd/yyyy) Length of Stay: Travel Date of Arrival (3): (mm/dd/yyyy) Length of Stay: Do you or did you hold a U.S. Driver's License? Have you ever been issued a U.S. Visa? If YES Date last Visa was issued Visa Number (8 digits in red print) 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 (fingerprinting) ? Has your U.S. Visa ever been lost or stolen? Has your U.S. Visa 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? If YES Date of application Reason: Please Explain: U.S. Contact information Contact Person Name in the U.S.: Organization Name in the U.S.: Relationship to You: U.S. Contact Address: Phone Number: Email Address: Family Information Father's Surnames and middle name: Father's Given Names: Father's Date of Birth: Is your father in the U.S.? Mother's Surnames and Middle name: 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.? If Yes, please indicate: Name Birthday Relationship Status (US Citizen, Immigrant) If YES, Status: If YES, Status:

Do you have any other relatives in the United States? If Yes, please indicate: Name Birthday Relationship Status (US Citizen, Immigrant)

Spouse's Full Name (including maiden name)

Spouse's Date of Birth: Spouse's Nationality Spouse's City of Birth Spouse's Country of Birth Spouse's Address: (Same as spouse?) Work/Education/Training Information Primary Occupation: Present Employer or School Name: Address: City: State/Province: Postal Zone/ZIP Code: Country: Monthly Salary in Local Currency: Briefly describe your Duties:

Were you previously employed? Company name: Company Address Street address: Company Address Street address: City: State/Province: Postal Zone/ZIP Code: Country: Telephone no. Job Title: Supervisor's surname: Supervisor's given names: Employment date from Employment date to: Briefly describe your Duties:

Have you attended any educational institutions other than elementary schools? Name of Institution (1): (High School) Address of Institution:

City: State/Province: Country: Course of Study: Date of Attendance From: (mm/dd/yyyy) Date of Attendance To: (mm/dd/yyyy) Name of Institution (2): (College) Address of Institution: City: State/Province: Country: Course of Study: Date of Attendance From:(mm/dd/yyyy) Date of Attendance To: (mm/dd/yyyy) Do you belong to a clan or tribe? Have you traveled to any countries within the last five years? If Yes, Country Visited (1): Country Visited (2): Have you belonged to, contributed to, or worked for any professional, social, or charitable organization? 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? Security and Background Information Do you have a communicable disease of public Health significance such as tuberculosis (TB)? Do you have a mental or physical disorder that Poses or likely to pose a threat to the safety or Welfare of yourself or others? Are you or have you ever been a drug abuser or addict? Have you ever been arrested or convicted for any Offense or crime, even though subject of a pardon, amnesty, Or other similar action? Have you ever violated, or engaged in a conspiracy to

Violate, any law relating to controlled substances? 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? Have you ever been involved in, or do you seek to engage In, money laundering? Do you seek to engage in espionage, sabotage, export control, Violations, or any other illegal activity while in the United States? Do you seek to engage in terrorist activities while in the United States Or have you ever engaged in terrorist activities? Have you ever or do you intend to provide financial assistance or Other support to terrorists or terrorist organizations? Are you a member or representative of a terrorist organization? Have you ever ordered, incited, committed, assisted, or otherwise Participated in genocide? Have you ever committed, ordered, incited, assisted, or otherwise Participated in torture? Have you committed, ordered, incited, assisted, or otherwise Participated in extrajudicial killings,political killings, or other acts Of violence? Have you, while serving as a government official, been responsible For or directly carried out, at any time, particularly sever violations of Religious freedom? 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? 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? Have you voted in the United States in violation of any law or regulation? Have you ever renounced United States Citizenship for the Purpose of avoiding taxation? Location Information Current Location: Preparer of Application: Did anyone assist you in filling out this application? Preparer Surnames: Preparer Given Names: Organization Name: Street Address: City: State/Province: Postal Zone/ZIP Code: Country: Relationship to You:

Note: Please send through email also your photo based on the photo specifications we have attached as we need to upload the picture Upon filling up the application form. Please make sure that the photo is in JPEG format image (i.e., .jpg file type) that is 240 KB or less in file size.