*PLEASE FILL IN CAPITAL LETTER/ ISI DENGAN HURUF BESAR

Full Name in Native Alphabet

Have you ever used other names (i.e., maiden, religious, Other Surnames Used (maiden, religious, professional, aliases, etc.)
professional, alias, etc.)?
YES / NO
Other Given Names Used (fill if your answer Yes)
Sex ( Male / Female )
Marital Status ( Married / Single / Widowed / Divorced / Legally Separated )

Date and Place of Birth

City of Birth
State/Province of Birth
Country of Birth

Nationality
Do you hold or have you held a nationality other than the
YES / NO
one you have indicated above?
Other Nationality (fill if your answer Yes)
Do you hold a passport for the other nationality above?
(fill if your answer Yes)
Passport Number (fill if your answer Yes)
National Identification Number
U.S. Social Security Number
U.S. Taxpayer ID Number

Street Address
City
State/Province
Postal Zone/ZIP Code
Country
Is your Mailing Address the same as your Home Address? YES / NO
(This is the address to which your passport will be sent if
you qualify for a visa).
Street Address (Fill if different)
City (Fill if different)
State/Province (Fill if different)
Postal Zone/ZIP Code (Fill if different)
Country (Fill if different)
Home Phone Number (Fill if different)
Mobile/Cell Phone Number
Email Address
Social Media - Account Name
Ask.FM : Sina Weibo :
Douban : Tencent Weibo :
Facebook : Tumblr :
Flickr : Twitter :
Google+ : Twoo :
Instagram : Vine :
LinkedIn : Vkontakte (VK) :
MySpace : Youku :
Pinterest : Youtube :
Qzone (QQ) : Other :
Reddit :
Passport Number
Country/Authority that Issued Passport
City
State/Province *If shown on passport
Country
Issuance Date
Expiration Date
Have you ever lost a passport or had one stolen? YES / NO

Passport Number: (fill if lost)

Country/Authority that Issued Passport: (fill if lost)
Explain (fill if lost)
Are there other persons traveling with you? YES / NO

Have you ever been in the U.S.?

YES / NO
(if Yes, fill your 5 last US Visit)
(1) Date of Arrival : (2) Date of Arrival :

Length of Stay : Length of Stay :

(3) Date of Arrival : (4) Date of Arrival :

Length of Stay : Length of Stay :

(5) Date of Arrival : (6) Date of Arrival :

Length of Stay : Length of Stay :

If you ever been in the U.S, Have you ever overstay? YES / NO

How long did you overstay in U.S.?

Do you or did you ever hold a U.S. Driver’s License? YES / NO

Driver's License Number (fill if your answer Yes)

State of Driver's License (fill if your answer Yes)
Have you ever been issued a U.S. Visa? YES / NO

Date Last Visa Was Issued (fill if your answer Yes)

Visa Number (fill if your answer Yes)
Are you applying for the same type of visa? YES / NO

Are you applying in the same country where the visa above YES / NO
was issued?
Is this country your principal country of residence? YES / NO

Have you been finger ten-printed? YES / NO

Has your U.S. Visa ever been lost or stolen? YES / NO

Year&Explain:

Has your U.S. Visa ever been cancelled or revoked? YES / NO

Explain:

Have you ever been refused a U.S. Visa, been refused YES / NO
Explain:
admission to the United States, or withdrawn your
application for admission at the point of entry?

Father Full Names

Date of Birth
Is your father in the U.S.? YES / NO

Father's Status (U.S. Citizen / U.S. Legal Permanent Resident (LPR) / Nonimmigrant / other (Idon't
know))
Mother Full Names
Date of Birth
Is your mother in the U.S.? YES / NO

Mother's Status (U.S. Citizen / U.S. Legal Permanent Resident (LPR) / Nonimmigrant / other (Idon't
know))

Number of Former Spouses:

Full Name
Date of Birth
Nationality
City
Country
Date of Marriage
Date Marriage Ended
How the Marriage Ended
Country Marriage was Terminated
Do you have any immediate relatives, not including parents, YES / NO
in the United States?
Provide the following information (fill if your answer Yes)
Surnames (fill if your answer Yes)
Given Names (fill if your answer Yes)
Relationship to You (fill if your answer Yes) Sibling / Fiance / Child / Spouse
Relative's Status (fill if your answer Yes) (U.S. Citizen / U.S. Legal Permanent Resident (LPR) / Nonimmigrant / other (Idon't
know))
Do you have any other relatives in the United States? YES / NO

Spouse's Full Name (include Maiden Name)

Spouse's Surnames
Spouse's Given Names
Spouse's Date of Birth
Spouse's Nationality
City
Country
Spouse's Address if different from your home address

Street Address (fill if different address)

City (fill if different address)
State/Province (fill if different address)
Postal Zone/ZIP Code (fill if different address)
Country (fill if different address)
Monthly Salary in Local Currency (if employed) (Rp………………......................)
Briefly describe your duties:

Have you ever violated, or engaged in a conspiracy to violate, any law relating to Explain:

controlled substances?
YES / NO
Are you coming to the United States to engage in prostitution or unlawful commercialized Explain:

vice or have you been engaged in prostitution or procuring prostitutes within the past 10
years?
YES / NO
Have you ever been involved in, or do you seek to engage in, money laundering? Explain:

YES / NO
Do you seek to engage in espionage, sabotage, export control violations, or any other Explain:

illegal activity while in the United States?

YES / NO
Do you seek to engage in terrorist activities while in the United States or have you ever Explain:

engaged in terrorist activities?

YES / NO
Have you ever or do you intend to provide financial assistance or other support to terrorists Explain:

or terrorist organizations?
YES / NO
Are you a member or representative of a terrorist organization? Explain:

YES / NO
Have you ever ordered, incited, committed, assisted, or otherwise participated in Explain:

genocide? YES / NO
Have you ever committed, ordered, incited, assisted, or otherwise participated in torture? Explain:

YES / NO
Have you committed, ordered, incited, assisted, or otherwise participated in extrajudicial Explain:

killings, political killings, or other acts of violence?

YES / NO
Have you, while serving as a government official, been responsible for or directly carried Explain:

out, at any time, particularly severe violations of religious freedom?

YES / NO
Have you ever been the subject of a removal or deportation hearing? Explain:

YES / NO
Have you ever sought to obtain or assist others to obtain a visa, entry into the United Explain:

States, or any other United States immigration benefit by fraud or willful misrepresentation
or other unlawful means?
YES / NO
Have you failed to attend a hearing on removability or inadmissibility within the last five Explain:

years?
YES / NO
Have you ever been unlawfully present, overstayed the amount of time granted by an Explain:

immigration official or otherwise violated the terms of a U.S. visa?

YES / NO
Have you ever withheld custody of a U.S. citizen child outside the United States from a Explain:

person granted legal custody by a U.S. court?

YES / NO
Have you voted in the United States in violation of any law or regulation? Explain:

YES / NO
Have you ever renounced United States citizenship for the purpose of avoiding taxation? Explain:

YES / NO
Have you attended a public elementary school on student (F) status or a public secondary Explain:

school after November 30, 1996 without reimbursing the school?

YES / NO

Have you ever visited U.S or other countries with non Seafarer Visa? YES / NO
COUNTRY YEAR of VISIT

Please list down names of country that you have visit within the last 5 (Five) years
COUNTRY YEAR of VISIT

Please tell us if any thing should be communicated about the US Visa process
Name and Crew ID : .......................................................................................... NEWHIRE / REPEATER
Were you previously employed? YES / NO
Employer Name (1) : HOLLAND AMERICA LINE
Employer Address: 450 Third Ave. West
City: SEATTLE
State/Province: WASHINGTON
Postal Zone/Zip Code: 98119
Country: UNITED STATES OF AMERICA
Telephone Number: +1 206 2863900
..................................................................................................................................
Job Title: .........................
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Supervisor's Name: .........................
Employment Date From: .......... / .......... / .............. [ dd / mm / yyyy ]
Employment Date To: .......... / .......... / .............. [ dd / mm / yyyy ]
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Briefly describe your duties: .........................
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.........................

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Employer Name (2) : .........................
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Employer Address: .........................
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City: .........................
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State/Province: .........................
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Postal Zone/Zip Code: .........................
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Country: .........................
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Telephone Number: .........................
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Job Title: .........................
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Supervisor's Name: .........................
Employment Date From: .......... / .......... / .............. [ dd / mm / yyyy ]
Employment Date To: .......... / .......... / .............. [ dd / mm / yyyy ]
..................................................................................................................................
Briefly describe your duties: .........................
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Reason of Resign: .........................

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Employer Name (3) : .........................
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Employer Address: .........................
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City: .........................
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State/Province: .........................
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Postal Zone/Zip Code: .........................
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Country: .........................
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Telephone Number: .........................
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Job Title: .........................
..................................................................................................................................
Supervisor's Name: .........................
Employment Date From: .......... / .......... / .............. [ dd / mm / yyyy ]
Employment Date To: .......... / .......... / .............. [ dd / mm / yyyy ]
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Briefly describe your duties: .........................
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Reason of Resign: .........................
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.........................
Have you attended any educational institutions other than elementary schools? YES / NO
..................................................................................................................................
Junior High School .........................
..................................................................................................................................
Name of Institution .........................
..................................................................................................................................
Address of Institution: .........................
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City: .........................
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State/Province: .........................
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Postal Zone/ZIP Code: .........................
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Country: .........................
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Course of Study: .........................
Date of Attendance From: .......... / .......... / .............. [ dd / mm / yyyy ]
Date of Attendance To: .......... / .......... / .............. [ dd / mm / yyyy ]
..................................................................................................................................
Senior High School .........................
Name of Institution (2) :
..................................................................................................................................
Address of Institution: .........................
..................................................................................................................................
City: .........................
..................................................................................................................................
State/Province: .........................
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Postal Zone/ZIP Code: .........................
..................................................................................................................................
Country: .........................
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Course of Study: .........................
Date of Attendance From: .......... / .......... / .............. [ dd / mm / yyyy ]
Date of Attendance To: .......... / .......... / .............. [ dd / mm / yyyy ]
..................................................................................................................................
Diploma / University .........................
..................................................................................................................................
Name of Institution (3) : .........................
..................................................................................................................................
Address of Institution: .........................
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City: .........................
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State/Province: .........................
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Postal Zone/ZIP Code: .........................
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Country: .........................
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Course of Study: .........................
Date of Attendance From: .......... / .......... / .............. [ dd / mm / yyyy ]
Date of Attendance To: .......... / .......... / .............. [ dd / mm / yyyy ]
..................................................................................................................................
Course .........................
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Name of Institution (4) : .........................
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Address of Institution: .........................
..................................................................................................................................
City: .........................
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State/Province: .........................
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Postal Zone/ZIP Code: .........................
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Country: .........................
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Course of Study: .........................
Date of Attendance From: .......... / .......... / .............. [ dd / mm / yyyy ]
Date of Attendance To: .......... / .......... / .............. [ dd / mm / yyyy ]

** TO BE FILLED IN BY SBI OFFICER:

ADDITIONAL REMARKS : Sign & Date
 SURAT PERNYATAAN

Saya Yang Bertanda Tangan di Bawah Ini:

Nama : …................................................................................................................
Crew ID : …................................................................................................................
Function : …................................................................................................................

Kontak Informasi
Alamat : …................................................................................................................
No Ponsel : …................................................................................................................
No Telp Lainnya : …................................................................................................................
Email : ….............................................................................................................…

Apakah Pengajuan CID US Visa anda pernah di “REJECT” ? : ________________ YA / TIDAK

Apakah Pengajuan CID US Visa anda pernah di “PENDING” ? : _______________ YA / TIDAK
Apakah anda pernah bermasalah di imigrasi negara manapun ? ______________ YA / TIDAK

Dengan Ini Menyatakan Bahwa:

1. Saya menyatakan bahwa semua informasi yang saya berikan di formulir aplikasi US Visa sudah tepat dan benar adanya.

2. Saya Menyatakan bahwa saya pasti dapat dihubungi setiap saat diantara nomor telepon dan/atau alamat email seperti
tersebut diatas.

3. Saya bersedia menyelesaikan semua kewajiban yang berhubungan dengan pengurusan visa, baik untuk kewajiban
pembayaran visa maupun kewajiban administratif lainya

4. Saya mengerti bahwa tanggal interview US visa ditentukan langsung oleh kedutaan dan saya menyanggupi untuk datang
ke SBI guna melakukan briefing, segera setelah diberitahu jadwal briefing tersebut.

5. Saya menyanggupi untuk berada di Kedutaan Amerika Serikat pada waktu dan tanggal interview yang telah
ditetapkan.

6. Saya bersedia menerima segala konsekuensi bila pihak Perusahaan ataupun Kedutaan menemukan hal-hal yang
bertentangan dengan aturan ataupun data palsu yang saya berikan kepada pihak Perusahaan, termasuk mengerti dan siap
menerima sanksi berupa pembatalan jadwal keberangkatan selama 6-12 bulan sampai dengan kategori pelanggaran berat
yaitu pemecatan.

7. Saya mengerti dan menyetujui bahwa apabila saya resign/mengundurkan diri sebelum akhir masa kontrak saya mendatang,
saya akan dikenakan denda sebesar Rp. 3.500.000 (Tiga juta lima ratus ribu rupiah)

8. Saya bersedia secara sadar dan memahami bahwa dalam proses pengisina DS 160 dilakukan oleh staff visa PT. SBI
berdasarkan data yang telah saya isi di formulir aplikasi visa yang telah saya isi sebelumnya.

Jakarta / Bali, …...............................…

(…...............................................................)
Nama / Crew ID