Onliù e.

Immigrant Vi sa and Ali en egistrati en Applicattön @ S- 260)

Personal, Address, and Phone Information

Note: You ha ve' completed data erit ry for your !Imm igrant V is a amd Alien Ré gistrat ion’ ap plicat ion'. B efo re s ubmitting th'e
application , plea s e re vie w your entrie s b elo w . To na gate t o the ne xt sect! on to be rev iéw e d, click the ‘Next’ biutt on on the
botto rh of' the p ag'e . If a'n entry is i na rre ct, click on. the li nk s on the rig ht side of the pa ge, w hich. w i\ I direct y ou t o the pa ge
where you ent ere d the data . On ce you hav e reyie w ed al| section s, you w ill be direct ed to the Fign and Submit p ag e' to
comp lete the ap plicat ion prole s s.

Name Prov ided:

SALIM , JARIEA BINTA
FuI I N am'e in N at ive Lan gu a ge:
DOES N OT APPLY/TEO-I NOLOGY NOT AVAILABLE
Other N arne s U se d:
Id O
S ex:
FEMALE
Current Ma ritaI St at us:
SINGLE
D at e of Birth:
08 JULY 2014
City of Birth:
CHATTO GR AM
State/Pro vince of 8 irth:
DOES N OT
Country/R egion of Birth:
APPLY

Coun'try/Region öf Origin (Nation alit y): BANGLADESH

Oocument Type:
BA hlGLADE
Document ID :
SH
Country/Authority th'at Issued IDocument : PASSPORT
I s suance Date: EF 0374594
E x pirati on Date: BANGLADESH
Do you hold or have you held any nation ality other than the 24 FEBRLIARY 2020
one you have indicated aöove?
23 FEBRLIARY 2025

P resent Ad dres s: NO

City: HC'ÜSE 27, ROAD 02, MO W SHUM I

State/Pro vince: RA TEST NA SiR ÄB AD, PAHARTOLY
P o st al Z on e/ZIP CHATTO GR AM
Code: Country/R egion: DOES N OT APPLY
From Date: DOES N OT APPLY
P rima ry P hon e Numb er: BANGLADESH
Second ar:y P hone Numb 3ULY 2014
er: W o rk P hon e Numb 01814 3 21988
er: DOES N ÖT
Other Teleph one N u'mb ers U se APPLY DOES N
d: E mail A ddres s: OT APPLY NO
 . dilrub ak äis er19 7 3 @ gmai] .com
Other EmitAddresses Used: NO

Social N!edia Provider/Platform: NONE NO

Other Social N!edia Used:
NO
Is your Mating Address the same as your PresentAddress7 KAISER GO BARI, VILL-MUSAPUR
Mailing Address: PS-SANDWIP
CHATTOGRAM DOES NOT
City: APPLY DOES NOT APPLY
State/Province: BANGLADESH
Postal Zone/ZIP Code:
Country/Repion:
N!OSAN!N!AT ANZUN!AN N!OWLA 272 E 39TH
PermanentAddress ST
Name of person c urrently living at address: 1FL
U.S. Add ress : BROOKLYN, NEW YORK 1 1 203
(7 18]436 -1877
YES
Phone Number:
Is this address where you vvantyour Permanent Residence
Card (Green Card) mailed ?
Onlin e Inn mig rant Vi sa and Ali en Regis trati on Application (D S-260)

Family Information

Father’s Surname s:
WADUD
Father’s Giv en Names:
MOHAMMED ABDUL
D at e of Birth:
01 JUNE 1970
City of Birth:
CHATTO GR AM
State/Pro vince of Birth:
DO NOT KNOW
Country/R egion of Birth:
BANGLADESH
I s y our father stil I liv ing? YES
Current A ddre ss: HOUSE 2 7, ROAD 02, MO W SHUM I

RA WEST NA SIR AB AD, PAH A RTO

City:
LY CHATTO GR AM
State/Province:
DOES N OT APPLY
P o st al Z on e/ZIP Code :
DOES N OT APPLY
Country/R egion:
BANGLADESH
M other’s Surname s at Birth:
KAISER
M other’s Giv en Names:
DILR UBA
D at e of Birth: 2 9 SEPTEMBER 1973
City of Birth: CHATTO GR AM
State/Pro vince of Birth: DO NOT KNOW
Country/R egion of Birth: BANGLADESH
I s y our mother still liv ing? YES
I s y our mother’s a ddre ss the s ame as your father’s ?
Current A ddre ss: HOUSE 27, ROAD 02, MO W SHUM I
RA WEST NA SIR AB AD,
City: PAHARTOLY CHATTO GR AM
State/Province: DOES N OT
P o st al Z on e/ZIP Code : APPLY DOES N
Co untry/R egion : OT APPLY

Do y ou ha v e an y P re v iou s Spo BANGLADESH

us es ? Do y ou ha v e an y children? NO

NO
Onliù e. Immigrant Vi sa and Ali en R egistrati en Applicattön @ S- 260)

Precious U.S. Travel Information

Have you ever been in the U .S .? NO

Have you ever been issued a U .S . Visa? NO
Have you ever been refcse d a U .S . Visa, been refus ed NO
admis sian to the Ufiited States, or withdrawn your appf ication
for admission at the port of entry?
Onlin e. Immigrant Vi sa and Ali en R egistrati en Applicatiön @ S- 260)

Petitioner Information

Petitioner is. my:

AUNT
Petitioner Name:
MOWLA MOSAMMAT ANZUMAN
Petitioner Address:
272 E 39TH ST
1FL
City:
BROOKLYN
State/Provinc.e:
NEW YORK
P o'st al Z on e/ZIP Code :
11203
Coun'try/R egion:
UNIT£D STAT£ S OF AMERICA
Telep hone:
(718)496-Z877
M obiIe/CäII Tele phone:
DOES N OT APPLY
E mdil A ddress:
mosammatmowla66@gmail.com
Onlin e lm mig rant Vi sa and Ali en R egis trati on Application (D S-260)

Security and Background Information

Do y ou ha v e a a mmuni cabIe dise ase of publie he alth significan ce s uch a s tub erculo sis (TB) ? NO
Do y ou ha v e do cumentation to estab lish th at you ha ve re ceiv ed v accin at ions in a cco rd ance w ith U .S. Ia w
? YES
Do you have a mental or ph y sical di sorder that poses or is likely to pose a threat to the safety or welfare

NO of yourself or others?
A re you o r ha ve you e ver be en a drug abuse r or a ddict ? NO

Ha v e y ou e ver be en arreste d or conv icte d for an y off en se o r crime, e ven th ough s ubj ect of a pard on, NO
amnesty, or other similar a ct ion?
Ha v e y ou e ver vi oIat ed, o r en ga ged in a cons pira cy to vi oIate, an y Iaw rel at ing t o co ntroIIed s ub st ance s ?
NO
A re you the s pou se, s on, or daught er of an indiv idu al wh o has violate d an y œntrolled s ub stanœ

NO traffick ing Iaw, and hav e kno w ingl y b enefite d fram the traffickin g a ctivit ies in the p ast fiv e y ea rs?

A re you coming to the Unite d St at es to en ga ge in prosti tution o r unIa wful a mmerci ali z e d vice o r hav e

NO y ou be en en gag e d in pro stitut ion o r pro curing prost itute s w ithin the p ast 10 y ea rs?
Ha v e y ou e ver be en in v ol ved in, or do y ou se ek to en ga ge in, money Iaunde ri ng? NO
Ha v e y ou e ver a mmitte d or cons pired to commit a hum an traffick ing off en se in the Unite d State s or NO
outside the Unit ed States ?
Ha v e y ou e ver kno w ingl y aided, ab ette d, a s sist ed, o r colluded w ith an indi vi dual wh o ha s b een ident ifie
d

NO b y the P resident of the Unite d St at es a s a p ers on wh o play s a significant role in a sev ere form of
traffick ing in p ers on s ?
A re you the s pou se, s on, or daught er of an indiv idu al wh o has committ ed o r consp ire d t o commit a NO
hum an t raffickin g offen se in the Unite d St at es o r outside the Unit ed State s and hav e y ou w ithin the Iast
fiv e y ea rs, know i ngl y b en efite d from the t raffickin g a ct ivit ies ?

Do y ou se ek to en ga ge in e sp iona ge, s ab ota ge, e xp o rt control v iol at ion s, o r an y other illeg al activ ity
while NO in the Unite d St at es ?

Do y ou se ek to en ga ge in terrorist a ct ivit ies while in the Unit ed States o r ha v e y ou e ver en ga ge d in NO

terrorist a ct ivit ies ?
Ha v e y ou e ver or do y ou int end t o prov ide fin ancial a s sist ance o r other s uppo rt to terrorists or terrorist

NO o rganiz ation s?
A re you a member or rep res entati v e of a t errori st o rganiz at ion? NO
A re you the s pou se, s on, or daught er of an indiv idu al wh o has en ga ged in terrorist a ct ivit y, includin g NO
prov idin g fin ancial as sistanœ or other s upp o rt t o t erro rists o r t errori st o rganiz ation s, in the Ia
st five y ea rs?
Ha v e y ou e ver ordere d, incit ed, committ ed, a s siste d, o r otherw ise p articip ate d in gen o ci de ?

NO Ha v e y ou e ver a mmitte d, ordere d, incit ed, a s siste d, o r otherw ise p articip ate d in t orture ?

NO
Ha v e y ou committed, o rdered, incite d, as siste d, or otherw ise particip at ed in e xt rajudiô al ki IIin gs, p olitical
NO k illings, o r other a ct s of violenœ ?
Ha v e y ou e ver en ga ged in the re cruit ment of o r the use of child s oldiers ? NO

Ha v e y ou, while servin g a s a go vemment offi ci al, b een res p on sibIe for o r directl y carried out, at an y time, NO
part icularl y se vere v iolation s of rel igiou s fre e dom ?

A re you a member of o r affiliate d w ith the Communist o r other totalita rian party? NO
Ha v e y ou e ver dire ctly o r indire ctly a s sist ed o r s upp o rt ed an y of the group s in Columb ia kno w n a s the

NO R ev olution ary Armed Fo rœ s of Columb ia (FARC) , Nation al Lib eration Arm y (ELN), o r Unite d Self- Defen
se
Fo rces of Columbia (AUC) ?
Have you ever, through abuse of go vernmental or politic a I position converted for personal gain, NO
confiscated or expropriated property in a foreign nation to which a United States nationa I had claim of
ownership?
Areyou thespouse, minor chitd,or agentofan indvduat who hasthrough abuseofgovernmentat or NO
politica I position converted for persona I gain, confiscated or expropriated property in a foreign nation to
which a United States national had claim of ownership?
Have you ever been direc tly invol ved in the establishment or enforcement of population controls forcing a NO
woman to undergo an abortion agai nst her free choice or a ma n or a woman to undergo sterilization
against his or her free choice?
Have you ever disc losed or trafficked in confidential U.S. business information obta ined in connection with NO
U.S. participation in the Chemical Wea pons Convention?
Are you the spouse, minor child, or agent of a n individua I who has disc losed or trafficked in confidential NO
U.S. business information obtai ned in connection with U.S. participation in the Chemica I Weapons
Convention?

Have you ever sought to obtain or assist others to obtain a visa, entry into the United States, or a ny other NO
United States immigration benefit by fraud or willful misrepresentation or other unlawful mea ns?
Have you ever been removed or depo rted from any cou ntry? NO

Have you ever withheld custody of a U.S. citizen child outside the United States from a person granted NO
legal custody by a U.S. court?
Have you ever intentionally assisted another person in withholding custody of a U.S. citizen child outside NO
the United States from a person granted lega I custody by a U.S. cou rt?
Have you voted in the United States in violation of any law or regulation ? NO
Have you ever renounced United States citizenship for the purpose of avoiding taxation? NO
Have you attended a public elementary school or a public secondary school on student (F) status after NO
November 30, 1996 without reimbursing the school?
Do you seek to enter the United States for the purpose of performing skilled or unskilled la bor but have NO
not yet been certified by the Sec reta ry of Labor?
Areyou agraduateofaforeign medcatschoot seekingto performmedcat servcesinthe United States NO
but have notyetpassed the National Board ofMedicat Examiners examination or its equivatent2

Are you a health ca re worker seeking to perform such work in the United States but have not yet received NO
certification from the Commission on Graduates of Foreign Nursing Schools or from an equivalent
a pprov ed independent c redentia ling organization?
Are you permanently ineligible for U.S. citizenship? NO
Have you ever departed the United States in order to evade military service during a time of wa r? NO
Are you coming to the U.S. to practice poly gamy ? NO
Are you a former exchange visitor (3) who has not yet fulfil led the two-year foreign residence NO
requirement?
Has the Secretary of Homela nd Security of the United States ever determined that you knowingly made a NO
frivolous application for asy lum?
Are you likeIy to become a public c harge after you a re a dmitted to the United States ? NO
Onlin e Inn mig rant Vi sa and Ali en Regis trati on Application (D S-260)

SOC1@ Security Number Information

Have you ever applie d for a Social Security number? NO

Do you want the Social Security Administration to issue a Social Security number and a card?

YES
Do y ou autho riz e dis clos ure of inform at ion from this form t o the D ep art ment of Homel and Se curit y, YES
the Social Se curit y A dministration, and s uch other U .S. G o vemment a gen cies a s ma y be re quire d
for the purp ose s of as signing you a s o cial security numb er (SSN) and is s uing you a S o ci al Se curity
card and do you autho riz e the So cial Security Administrat ion t o s hare your SSN w ith the
D ep art ment of Homel and Se curit y?