Personal, Address, Phone, and Passport Information

Name Provided:
Full Name in
Native Language:
Other Names Used
(i.e., maiden, religious, professional, alias, etc.):
Sex:
Marital Status:
Date of Birth:
Place of Birth:
Nationality:
Other Nationalities: □ Yes □ No
Do you hold a passport for □ Yes □ No
the other nationality above? Passport Number:
National Identification
Number:
U.S. Social
Security Number:
U.S. Taxpayer ID Number:
Home Address:
City:
State/Province:
Postal Zone/ZIP Code:
Country:
Same Mailing Address? □ Yes □ No
Address:
City:
State/Province:
Postal Zone/ZIP Code:
Country:
Home Phone Number:
Work Phone Number:
Work Fax Number:
Mobile/Cell Phone Number:
Email Address:
Passport Number:
Passport Book Number:
Country/Authority that
Issued Passport:
City Where Issued:
Country Where Issued:
Issuance Date:
Expiration Date:
Have you ever lost a □ Yes □ No
passport or had one stolen? Passport Number:
Country/Authority that Issued Passport :
Travel Information
Are you the principal applicant? □ Yes □ No
Purpose of Your Trip to U.S.:
Specific Travel Plan? □ Yes □ No
Date of Arrival in U.S.:
Arrival Flight:
Arrival City:
Date of Departure from U.S.:
Departure Flight:
Departure City:
The Location you plan
to visit in the U.S.:
Address where you
will stay in the U.S:
Person/Entity
Paying for Your Trip:
Name of Company/
Organization Paying for Trip:
Telephone:
Relationship to You:
Is the address of the party paying for your□ Yes □
No
trip the same as your Home or Mailing Paying Address:
Address?
City:
State/Province:
Postal Zone/ZIP Code:
Country:
Other Persons Traveling □ Yes No□
with You: Surname:
Given Name:
Relationship with Person:
Are you traveling as part of □ Yes No□
a group or organization? Group Name:
Have you ever been in the U.S.? □ Yes □
No
Provide information on Date of Arrival:
your last five U.S. Visits: Length of Stay:
Do you or did you hold a □ Yes □No
U.S. Driver's License? Driver's License Number:
State of Driver's License:
Have you ever been issued □ Yes □
No
a U.S. Visa? Date Last Visa was Issued:
Visa Number:
Are you applying for the
same type of visa? □ Yes □ No
Are you applying in the same
country where the visa above is issued? □ Yes □ No
Have you been ten-printed? □ Yes □ No
Has your U.S. Visa ever been □ Yes □ No
lost or stolen? Year visa was lost or stolen:
Has your U.S. Visa ever been □ Yes □ No
cancelled or revoked? Explain:
Have you ever been refused a U.S. Visa? □ Yes □ No
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:
Father's Given Names:
Father's Date of Birth:
Is your father in the U.S.? □ Yes □ No
Father's Status:
Mother's Surnames:
Mother's Given Names:
Mother's Date of Birth:
Is you mother in the U.S.? □ Yes □ No
Mother's Status:
Do you have any immediate relatives, □ Yes □ No
not including parents in the U.S.? Surnames:
Given Names:
Relationship to You
Relative's Status:
Do you have any other relatives □ Yes □ No
in the United States? Surnames:
Given Names:
Relationship to You
Relative's Status:
Spouse's Full Name:
Spouse's Date of Birth:
Spouse's Nationality:
Spouse's City of Birth:
Spouse's Country of Birth:
Spouse’s Address:

Work / Education / Training Information

Primary Occupation:
Present Employer or School Name
Address:
City:
State/Province:
Postal Zone/Zip Code:
Country:
Month Salary in Local Currency:
Briefly Describe your Duties:
Were you previously employed? □ Yes □ No
Name of Employer:
Address of Employer:
City:
State/Province:
Postal Zone/ZIP Code:
Country:
Telephone Number:
Job Title:
Name of Supervisor:
Date of Attendance From:
Date of Attendance To:
Briefly describe your duties:
Have you attended any educational □ Yes □ No
institutions other than elementary schools? Name of Institution:

Address of Institution:
City:
State/Province:
Postal Zone/ZIP Code:
Country:
Course of Study:
Date of Attendance From:
Date of Attendance To:
Do you belong to a clan or tribe? □ Yes □ No
Have you ever been in any □ Yes □ No
country other than U.S.? Countries Visited:
Have you belonged to, contributed to, or
worked for any professional, social, or □ Yes □ No
charitable organization?
Do you have any specialized skills or
training, including firearms, explosives,
nuclear, biological, or chemical □ Yes □ No
experience?
Have you ever served in the military? □ Yes □ No
Have you ever served in, been a
member of, or been involved with a
paramilitary unit, vigilante unit, rebel □ Yes □ No
group, guerrilla group, or insurgent
organization?

Security and Background Information

Do you have a communicable disease
of public health significance such as □ Yes □ No
tuberculosis (TB)?
Do you have a mental or physical
disorder that poses or is likely to pose
a threat to the safety or welfare of □ Yes □ No
yourself or others?
Are you or have you ever been a drug
abuser or addict?
□ Yes □ No
Have you ever been arrested or
convicted for any offense or crime,
even though subject of a pardon, □ Yes □ No
amnesty, or other similar action?
Have you ever violated, or engaged in
a conspiracy to violate, any law □ Yes □ No
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
□ Yes □ No
prostitutes within the past 10 years?
Have you ever been involved in, or do
you seek to engage in, money □ Yes □ No
laundering?
Do you seek to engage in espionage,
sabotage, export control violations, or
any other illegal activity while in □ Yes □ No
the United States?
Do you seek to engage in terrorist
activities while in the United States or
have you ever engaged in terrorist □ Yes □ No
activities?
Have you ever or do you intend to
provide financial assistance or other
support to terrorists or terrorist □ Yes □ No
organizations?
Are you a member or representative of
a terrorist organization? □ Yes □ No
Have you ever ordered, incited,
committed, assisted, or □ Yes □ No
otherwise participated in genocide?
Have you ever committed, ordered,
incited, assisted, or otherwise □ Yes □ No
participated in torture?
Have you committed, ordered, incited,
assisted, or otherwise participated in
extrajudicial killings, political killings, □ Yes □ No
or other acts of violence?
Have you, while serving as a
government official, been responsible
for or directly carried out, at any time, □ Yes □ No
particularly severe violations of
religious freedom?
Have you ever been the subject of a
removal or deportation hearing? □ Yes □ No
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 □ Yes □ No
fraud or willful misrepresentation or
other unlawful means?
Have you failed to attend a hearing on
removability or inadmissibility within □ Yes □ No
the last five years?
Have you ever been unlawfully
present, overstayed the amount of
time granted by an immigration official □ Yes □ No
or otherwise violated the terms of a
U.S. visa?
Have you ever withheld custody of a
U.S. citizen child outside the United
States from a person granted legal □ Yes □ No
custody by a U.S. court?
Have you voted in the United States in
violation of any law or regulation? □ Yes □ No
Have you ever renounced United
States citizenship for the purpose of □ Yes □ No
avoiding taxation?
Have you attended a public
elementary school on student (F)
status or a public secondary school □ Yes □ No
after November 30, 1996 without
reimbursing the school?

Location Information
Current Location: MANILA, PHILIPPINES

Preparer of Application:
Did anyone assist you in filling out □ Yes □ No
this application? Preparer's Surnames:
Preparer's Given Names:
Organization Name:
Address:
City:
State/Province:
Postal Zone/ZIP Code:
Country:
Relationship to You: