QUESTIONNAIRE FOR DS160 – C1/D VISA

Please fill below questionnaire to the best of your knowledge. Information provided in this
form will be introduced to the US embassy in the country were you will apply for the C1/D
visa.

1. Last First
name: Name:
2. First (Given) name of your grandmother:
(important - security question for entering your application)
3. Marital status: (single-married-divorced-widowed):
If you are married, please fill below:
A: First name and last maiden name of
your spouse:
B: His/hers date, place and country of
birth:
C: His / hers current residential address:
If you are devorced, please fill below:
A: First name and last maiden name of
your spouse:
B:Date of his/her birth:
C:Place of birth:
D:Marriage date:
E:Divorce date:
F:Country where marriage has been
divorced:
5. Date of birth:
6. Place of birth:
7. Nationality:
7.1 Personal ID number (JMBG):
8. Do you have passport of any other country:
( yes / no ):
If yes, please fill below:
A: Country of issue:
B: Passport number:
C: Date of issue:
D: Place of issue:
C: Date of expire:
9. Permanent address: (street, city and
country):
10. Current address: (street,city ans country)
SAME
If same as permanent, write
11. Your contact details:
A: Your cell ( mobile )
phone no:
B: Landline phone number:
C: Have you used any other
phone numbers in the
last five years? (If yes,
write number)
D: Your email address:
E: Have you used any other
email addresses in the last
five years? If yes, write the
email address

11a Social media: Do you have any social medial presence ?

7.4.2022. 21:48
QUESTIONNAIRE FOR DS160 – C1/D VISA

Write below each social media platform you have used within the last five years.
In the space next to the platform’s name, type the username or handle you have
used on that platform. Please do not provide your passwords. If you have used
more than one platform or more than one username or handle on a single
platform, please write next. If you have not used any of the listed social media
platforms in the last five years, write 'None.'
A: Facebook -Your username?
B: Your username ?
C: Twitter – Your username
D: LinkedIn – Your username?
E: Any other social media?
11b Do you wish to provide information about your presence on any other websites
or applications you have used within the last five years to create or share
content (photos, videos, status updates, etc.)?
Yes No
11c Please provide the name of the platform and the associated unique social media
identifier (username or handle) for each social media platform you would like to
list. This does not include private messaging on person-to-person messaging
services, such as WhatsApp.
A: Additional Social Media
Platform?
B: Additional Social Media
Handle?
12: Passport informations:
A: Passport issuing country:
B: Passport number:
C: Date of issue:
D: Place of issue:
F: Date of expire:
Did your passport ever been stolen or lost?
If so, please explain: (circumstances and the date)
13: Have you ever been to USA: ( yes / no ):
If yes, please fill below:
A: Dates of last 3 entrances
in USA:
B: Type of US visa used to
enter:
C: How long you stayed in
USA: (days, month, years)
If you are a seaman just transiting the United
States, please include the exact dates of
embarkation (start of the contract) and
disembarkation (end of the contract) in USA:
13a Have you ever been traveling outside of
your country in last five years ( yes / no )
If yes, please name each country you visited in
last 5 years:

14: Have your ever been denied USA

visa: (is yes, when, why and for
which US visa you applied)
15: Have you ever been issued USA
visa:(yes / no):
If yes, please fill below:
A: Date of visa issue:
B: Visa expiration date:

7.4.2022. 21:48
QUESTIONNAIRE FOR DS160 – C1/D VISA

C: Type of visa:
D: Visa number:
E: City and country where
your visa was issued:
16: Do you have or have you ever had American
driver's license?
( if yes, plase give a license number and which
was the USA state of isssue ):
17: Parental informations:
A: Father last name:
B: Father first name:
C: Father’s date of birth:
D: Fathers nationality:
E: Mother last name:
F: Mother first name:
G: Mothers date of birth:
H: Mothers nationality:
18: Do you have anyone close relatives in USA?
If yes, who?
If you have immediate relatives like fiance, spouse, child, sibling,
please fill below information’s:
Last / First name:
Relation to you:
Status in US: (US citizen, US leagal
permanent resident, non-immigrant)
19: Do you speak any other language beside
English: If yes, which ?
20: Are you currenty employed: (yes / no):
21: Current or last employer: ( Has to be real employment no matter
if you worked legally or not )
A: Employing company
name:
B: Company full address:
C: Manager last and first
name:
D: What was your position:
E: Starting date of
employment:
F: Ending date of
employment:
22: Have you ever been arrested or
convicted for any offence or
crime? ( yes / no )
If yes, please
explain:
23: In which city /country you will
apply for US visa:
24: Information about your embarkation: ( please fill below ):
A: Company name:
B: Name of the ship:
C: Embarkation date:
D: Your position:

7.4.2022. 21:48
QUESTIONNAIRE FOR DS160 – C1/D VISA

Education:
A: Name of the highest education
institution you have been
attending
B: Full address of the institution:
C: Vocation:
D: Attending dates: (start – finish)
26: FOR MALE CANDIDATES ONLY:
Military service:
A: Did you serve military: (yes / no)
If yes, please fill below:
B: In which country:
C: Military speciality:
D: Rank:
E: Military service starting date:
F: Military service end date:

7.4.2022. 21:48