FULL NAME,
CIVIL STATUS
BIRTHDAY BIRTHPLACE:
[COMPLETE ADDRESS
[CONTACT NOIS.
PASSPORT # PLACE OF ISSUANCE:
ISSUANCE DATE:
EXPIRATION DATE:
HAVE YOU LOST AUS VISA/PASSPO!
RT? NOL] YEs[_] REASON:
LAST VISIT IN U.S.A:
DAYS OF STAY:
LAST US VISA ISSUANCE DATE|
TYPE OF VISA: PLACE OF IS:
SUI
[ANY EXISTING US VISA: B12 L) NONE(_) ance
FIRST TIME RENEWALL_J
[ANY PRIOR VISA REFUSAL
FATHER'S FULL NAME
FATHER'S BIRTHDATE,
MOTHER'S FULL MAIDEN NAME
TJponor know
MOTHER'S BIRTHDATE
Tibonor Know.
[SPOUSE'S FULL MAIDEN NAME.
[SPOUSES BIRTHDATE.
ISPOUSE'S PLACE OF BIRTH
PETITION TOUSA,
OTHER RELATIVES IN THE U.S]
PREVIOUS COMPANY (IF NEW HIRE):
RELATIONSHIP:
ADDRESS
CONTACT NO.
(OCCUPATIONIRANK
BRIEFLY DESCRIBE YOUR DUTIES|
IMONTHIYEAR START & END
(SCHOOL GRADUATED (TERTIARY):
SCHOOL ADDRESS.
COURSE,
MONTH & VEAR STARTED
MONTH & YEAR GRADUATED
COUNTRIESVISITED
WITHIN THELAST SyRS__ —f
POSITION ON BOARD
lapes 2x2 size
lformal attire (neck tie)
Iwhite background
\visible eyebrows and ears
Ineutral f