DETAILS FOR US VISA APPLICATION

1) Surname as per Passport : ____________________________________

2) Given Name as per Passport : ____________________________________

3) Sex : ____________________________________

4) Date of Birth : ____________________________________

5) Place of Birth : ____________________________________

6) State of Birth : ____________________________________

7) Nationality : ____________________________________

8) Passport No. : ____________________________________

9) Place of Passport Issued : ____________________________________

10) State of Passport Issued : ____________________________________

11) Country of Passport Issued : ____________________________________

12) Date of Issue : ____________________________________

13) Date of Expiry : ____________________________________

14) Have you ever lost a passport or had one stolen : _____________________

15) Marital Status : ____________________________________

16) If Married; Spouse’ Name : ____________________________________

17) Spouse Date of Birth : ____________________________________

18) Spouse Place of Birth : ____________________________________

19) : ____________________________________
Home Address with Pincode No.
________________________________________________________________

20) Mobile No. : ____________________________________

21) Home No. : ____________________________________

22) E-mail ID : ____________________________________

23) Have you been in the US lately, If YES write DD/MM/YY (You will have to
write the date when you embarked on the ship e.g. 6 or 8 months back date)

24) If YES, how many Days, Months, Year : ____________________________________

25) Have you been issued a US Visa; If YES When, Where & Type of Visa :
____________________________________

26) Have you been refused a US Visa; If YES When, Where & Type of Visa :
____________________________________
If US visa refused earlier then Explain: _______________________________________
27) Do you intend to work in the US : NO .

28) Has your US Visa ever been Cancelled or Revoked : .

29) Has anyone ever filed an immigrant visa petition on your behalf : NO .

30) Father’s Name : ____________________________________

31) Father’s Date of Birth : ____________________________________

32) Mother’s Name : ____________________________________

33) Mother’s Date of Birth : ____________________________________

34) List of all countries you have last visited (last 5 years) :
____________________________________

35) Present Company Name/ Address & Telephone No. : ______________________

___________________________________________________________________

____________________________________________________________________

36) Position in the Company : ____________________________________

37) Supervisors Name : ____________________________________

38) Date of Joining dd/mm/yy : ____________________________________

39) Current Salary per month : ____________________________________

40) Brief Description of your Job : ____________________________________

________________________________________________________________

________________________________________________________________

41) Previous Company Name/ Address & Telephone No. : ________________

______________________________________________________________

______________________________________________________________
42) Position / Supervisors Name/ Salary: ______________________

_______________________________________________________________________

43)
Date of Joining dd/mm/yy _____________ TO dd/mm/yy _______________

44) Brief Description of your Job : ____________________________________

___________________________________________________________________

45) Name of Institute/ College : ____________________________________

46) Address of Institute/ College : ____________________________________

_________________________________________________________________

47) Course of Study : ____________________________________

48) Date of joining dd/mm/yy _____________ TO dd/mm/yy ________________

I hereby confirm that the information stated herein is truthful and accurate

Signature ________________ Date ______________ Place ___________

49) Languages known :____________________________________________

Documents required :
Passport copy [latest] front & back page
Previous US visa copy; if any
 Authorization Form for Assistance with C1/D Visa

I,……………………………………………………………………………….hereby authorize / do not authorize Indus

Cruising and Shipping to assist me with the visa application formalities as I am unable/ able to
process my C1/D visa on my own.

I agree to pay Rs. 5400 as US visa facilitation fees to Indus Cruising & Shipping. I understand
that there is no guarantee for the C1/D visa to be granted and that the fee is non refundable
by Indus Cruising & Shipping or Carnival cruise lines/Costa cruises/Apollo Ships /Crystal
cruises/Sea Chefs.

Name:………………………………………..

Signature: …………………………………….

Date : …………………………………..