Consuiar Electlonic Application Center - Frint Appiicatiou Page 4 of 5

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Do you seek to engage in terrorist activities while in the United States or have you ever engaged rn terrorist activities?
NO
Ilave you ever or do you intend to provide financial assistance or other support to terrorists or terrorist organizations?
NO
Are you a member or representative of a terrorist organizatton;
NO
Have you ever ordered, incited, commrlted, assisted, or otherr, se participated in genocide?
NO
Have you ever conlmitted, ordered, rnc ted, assisted, or otherr..rse participated in torture?
NO
Have you committed, ordered, inc ted, assisted, or otherwise p:ticipated in extrajudicial killings, political killings, or NO
other acts of violence?

Have you ever engaged in the recruitment or the use of the ch d soldiers?
NO
Have you, while serving as a government official, been respois 5je for or directly carried out, at any ttrne, particularly
NO
severe vtolations of religious freedom?

Have you ever been directly involved in the establishment or :i'orcement of the popu at oii contro s forcrng
a woman NO
to uildergo an abortion against her free choice or a man or a ,.,Jman to undergo sterilizai cn aEa nst h s or her free
will?

Have you ever been d rectly involved in the coercive transp e-::tion of human organs or bodily t ssue? NO
Have you ever sought to obtain or asstst others to obtain a ! sa. entry into the United States, or any other UniteC NO
States immigration benefit by fraud or !rlllful misrepresenta::^ oi- other unlawful means?

Have you ever withheld custcdy of a U.S. citizen child outs :: :he Unitecl States from a person grantec ega cjstody NO
b',,'a U,S, court?

lla'e you voted in the United States in violation of any lar^; :- :egulation? NO
Have you cver Tenounced United States citizenship forthe :--:ose ofavoiding taxation?

Location Information
Location where- you will be submitting your application

Current Locatic 1: K]NGSTON, ]AMA]CA

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Did anyone assist you in filling out thrs appl ca::-r YES
Preparer Surnames: D EANS

P'eparer Given Names: SHAUNA KAYE

Organization Name: NATIONAL TRAVEL SERVICE
Street Address: MOSLEY DR

LUCEA P.O
City:

State/Province:
HANOVER

DOES NOT APPLY

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Poslal Zone/ZIP Code: DOES NOT APPLY
Country/Region: ]AMAICA
Relationship to you: TRAVEL AGENT

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You electronically signed your application on 25-Feb-2015 02r55:26. You were required
yourself, unless otherwise exempt by regulation, even if the application was prepared
to electronically sign your application
by someone other than yourself, your
electronic si6iature certifies that you have read and understood thu qr"rtions in this
I application anc that your answers are true and
correct to the best of your knowledge and belief. The sLrbmission of an application containing
any false or misleading statements may
result in the permanent refusal of a vjsa or the denial of entry into the unlted states.
nll declaraiions made in this application are
unsworn decia|ations made under penalty of perjury. (28 U.S.C. 1746).

The iniorrnation that you have provided in your applicatlon and other information
submitted with your application may be accessible
to other government agencies having statutory or other larvful authorrty to use such information,
jmmigration law enforcement purposes. The photograph including for law enforcement and
that you provide with your application may be used for employment
verification or other U.S. law purposes.

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https://ceac.state.gov/GenNlV/common/printapplication.aspx?vKxJy6V30Ap3b
a%2ffTH... 2510212015