Personal Information

Please include copies of the following documents; National ID Card, Passport & Visa (if applicable)
PHOTO (5cm x 5cm) WITH NO GLASSES (WHITE OR OFF-WHITE BACKGROUND)

Name (first name & last name)

Maiden Name (if applicable)

Primary Contact Number

E-Mail Addresses Used within the last 5 years

Marial Status City of Birth

Home Address

Mailing Address (if different from home address)

Contact Number Used within the last 5 years

Do you hold or have you held a Nationality in another country?

If you have a passport for that coutry, please provide passport number even if expired

Are you a permenant resident of a country/region other than your origin?

If 'yes', please provide the name of the country Yes No

Social Media
Example; Facebook, Instagram, Twitter, Youtube, Douban, Flickr, Google+, LinkedIn, Myspace, Pinterest, Qzone,
Reddit, Sina Weibo, Tumblr, Twoo, Vine, Vkontakte (VK), Youku

Media Platform Username

If you are registered to any social media platform not listed, please include above
 Work Information

Current Employer Previous Employer

Employer's Name

Job Title and Duties

Supervisor's Name

Employer's Address (street

name, city)

Employer's Contact Number

Employment Date (Start & End)

Education
List all institutions secondary level or higher in order attended

Secondary / Teriary Secondary / Teriary Secondary / Teriary

Name of Institution

Course of Study
(e.g O-Level, A-Level, Degree
Name)

Address & Contact Number

Attended from (month & year)

Attended to (month & year)

Provide a list of languages you speak including English

Do you have any specialized skills or training, including firearms, explosives, nuclear, biological,
Yes No

Have you ever served in the military?

Yes No

Have you belonged to, contributed to, or worked for any professional, social, or charitable organization?
Yes No

Have you ever committed or conspired to commit a human trafficking offense in the United
States or outside the United States?
Yes No

Have you ever engaged in the recruitment or the use of child soldiers?
Yes No
 Family Information

Mother Name (First Name & Last Name)

Mother's DOB

Is your mother currently in the US? Yes No

Father Name (First Name & Last Name)

Father's DOB

Is your father currently in the US? Yes No

Do you have any immediate family in the US? Yes No

First Name Last Name Relationship US Status (e.g Resident / Citizen)

Do you have any other relatives in the US? (e.g Aunt, Uncle, Cousin, Neice/Nephew)
Yes No

Spouse (Complete even if Divorced)

First Name Last Name

Date of Birth Nationality

Country of Birth City of Birth

Address

IF Divorced, Provide the below details

Date of Marriage Date Marriage Ended

Reason for Divorce Country Marriage was Terminated

 Travel Information

Purpose of Trip to the U.S (e.g Business, Vacation)

Have you made specific plans? Yes No

Intended Travel Date Intended Length of Stay

Contact Name / Organization in the U.S of where you will be staying

Relationship

U.S address of where you will stay during your trip; Include Street, City, State & Postal Code

Phone number of U.S contact E-Mail Address of U.S contact

Have you ever has a US Driver's Permit? Yes No Do you have a US Social Security Number?

Person Paying for your trip, if other than yourself

Full Name / Company Name Relationship Contact Number E-mail Address

Are you traveling as part of a group? If 'yes' please list

Full Name Relationship (e.g friend, parent, relative)

Have you ever been issued a U.S Visa? Yes No Visa Number (red number on Visa)

Have you ever been to the U.S? If yes, please list last 5 visits and length of stay in the US

Have you ever been refused a U.S Visa or been refused admission to the U.S, or withdrawn your application for admission at the
port of entry? If 'yes', please provide details

Has anyone ever filed an immigrant petition on your behalf with the U.S Citizen & Immigration Services

List Countries you visited in the last 5 years