Fillable – Sample Form

(Separate Form for Each Applicant)

( Please fill Each and Every details, as required )

ONLINE Non-immigrant Visa Application (DS-160)

Edit Personal Information

Name Provided: SHAH HARESH BHAGWANDAS

Full Name in Native Alphabet: DOES NOT APPLY
Other Names Used: NO
Telecode Name Used: NO
Sex: MALE
Marital Status: MARRIED
Date of Birth: 28 JANUARY 1946
Country/Region of Birth: SURAT, GUJARAT, INDIA
Country/Region of Origin
INDIA
(Nationality):
Do you hold or have you held any
nationality other than the one NO
indicated above on nationality?
National Identification Number: DOES NOT APPLY
U.S. Social Security Number: DOES NOT APPLY
U.S. Taxpayer ID Number: DOES NOT APPLY
Edit Address and Phone
Information
Home Address: 23-24 OM SOCIETY
NEAR GATE
City: ABCD
State/Province: GUJARAT
Postal Zone/ZIP Code: 400000
Country/Region: INDIA
Same Mailing Address? YES
Primary Phone Number: 079-1234567
Secondary Phone Number: 91-912345678
Work Phone Number: 0261- 123456
Email Address: ABCD@rediff.com
Edit Passport/Travel Document Information
Passport/Travel Document Type: REGULAR
Passport/Travel Document
E9123456
Number:
Passport Book Number: DOES NOT APPLY
Country/Authority that Issued
INDIA
Passport/Travel Document:
City where issued: BARODA
Country/Region where issued: INDIA
Issuance Date: 07 JULY 2004
Expiration Date: 06 JULY 2014
Have you ever lost a passport or
NO
had one stolen?

Edit Travel Information

The List of Purposes of Trip to the U.S.

TEMP. BUSINESS PLEASURE

Purpose of Trip to the U.S. (1):
VISITOR (B)
TOURISM/MEDICAL
Specify:
TREATMENT (B2)

Have you made specific travel

NO
plans?
Intended Date of Arrival: 01 DECEMBER 2013
Intended Length of Stay in U.S.: 4 WEEK(S)

Address where you will stay in the 1234 BLUFF DRIVE,

U.S.: NEW YORK
NY 22334

Person/Entity Paying for Your Trip: SELF

Edit Travel Companions
Information
Other Persons Traveling with You: YES
Are you traveling as part of a
NO
group or organization?
Persons Traveling with You:

Name (1): JARIWALA , BHANUBEN

Relationship to You: SPOUSE

Edit Previous U.S. Travel

Information
Have you ever been in the U.S.? NO
Have you ever been issued a U.S.
NO
visa?
Have you ever been refused a
U.S. Visa, or been refused
admission to the United States, or YES
withdrawn your application for
admission at the port of entry?
Explain: 10 JAN 2008 - B2
Has anyone ever filed an
immigrant petition on your behalf
NO
with the United States Citizenship
and Immigration Services?

Edit U.S. Point of Contact Information

Contact Person Name in the U.S.: MRS A B PATEL
Organization Name in the U.S.: DOES NOT APPLY
Relationship to You: SISTER
1234 DRIVE,
U.S. Contact Address: NEW YORK
NY 23834

Phone Number: 123 456 8023

Email Address: Ka1234@gmail.com

Edit Family Information: Relatives

Father's Surnames: JARIWALA
Father's Given Names: LAXMANDAS
Father's Date of Birth: 03 APRIL 1918
Is your father in the U.S.? NO
Mother's Surnames: JARIWALA
Mother's Given Names: RADHABEN
Mother's Date of Birth: 21 JULY 1922
Is your mother in the U.S.? NO
Do you have any immediate
relatives, not including parents in NO
the U.S.?
Do you have any other relatives
NO
in the United States?
Edit Family Information: Spouse
Spouse's Full Name: JARIWALA, MEENA
Spouse's Date of Birth: 07 AUGUST 1949
Spouse's Country/Region of
INDIA
Origin (Nationality):
Spouse's City of Birth: SURAT
Spouse's Country/Region of Birth: INDIA
Spouse’s Address: SAME AS HOME ADDRESS

Edit Present Work

Information
Primary Occupation: BUSINESS
Present Employer or School
ABCD INDUSTRIES
Name:
Present Employer or School
FULL ADDRESS
Address:
BARODA
City: BARODA
State/Province: GUJARAT
Postal Zone/Zip Code: 3
Country/Region: INDIA
Work Phone Number: 079-1234567
Monthly Salary in Local Currency
DOES NOT APPLY
(if employed):
PARTNER OF M/S ABCD
Briefly Describe your Duties:
INDUSTRIES
Edit Previous Work
Information
Were you previously employed? NO
Have you attended any
educational institutions at a YES
secondary level or above?

Name of Institution (1): UNIVERSITY OF BARODA

Address of Institution: BARODA
City: BRODA
State/Province: DOES NOT APPLY
Postal Zone/ZIP Code: 123456
Country/Region: INDIA
POST GRADUATE DIPLOMA IN
Course of Study: TECHNICAL TECHNOLOGY -
TEXTILE PROCESSING
Date of Attendance From: 10 AUGUST 1970
Date of Attendance To: 07 JULY 1971
THE MAHARAJA SAYAJIRAO
UNIVERSITY - FACULTY OF
Name of Institution (2):
TECHNOLOGY AND
ENGINEERING
Address of Institution: KALABHAVAN
City: BARODA
State/Province: GUJARAT
Postal Zone/ZIP Code: DOES NOT APPLY
Country/Region: INDIA
BACHELOR OF TEXTILE
Course of Study:
(TECHNOLOGY)
 Date of Attendance From: 10 JUNE 1965
Date of Attendance To: 10 MAY 1970

Edit Additional Information

Do you belong to a clan or tribe? NO
Provide a List of Languages You Speak:

Language Name: (1): ENGLISH

Language Name: (2): HINDI
Language Name: (3): GUJARATI

Have you traveled to any

countries within the last five YES
years?

Country Visited (1): A

Country Visited (2): B
Country Visited (3): C

Country Visited (4): UNITED KINGDOM

Have you belonged to,

contributed to, or worked for any
NO
professional, social, or charitable
organization?
Do you have any specialized skills
or training, including firearms,
NO
explosives, nuclear, biological, or
chemical experience?
Have you ever served in the
NO
military?
Have you ever served in, been a
member of, or been involved with
a paramilitary unit, vigilante unit, NO
rebel group, guerrilla group, or
insurgent organization?

Edit Part 1
Do you have a communicable disease of public health NO
significance? (Communicable diseases of public significance
include chancroid, gonorrhea, granuloma inguinale, infectious
leprosy, lymphogranuloma venereum, infectious stage syphilis,
active tuberculosis, and other diseases as determined by the
Department of Health and Human Services.)
Do you have a mental or physical disorder that poses or is likely
NO
to pose a threat to the safety or welfare of yourself or others?
Are you or have you ever been a drug abuser or addict? NO
Edit Part 2
Have you ever been arrested or convicted for any offense or
crime, even though subject of a pardon, amnesty, or other NO
similar action?
Have you ever violated, or engaged in a conspiracy to violate,
NO
any law relating to controlled substances?
Are you coming to the United States to engage in prostitution
or unlawful commercialized vice or have you been engaged in NO
prostitution or procuring prostitutes within the past 10 years?
Have you ever been involved in, or do you seek to engage in,
NO
money laundering?
Have you ever committed or conspired to commit a human
trafficking offense in the United States or outside the United NO
States?
Are you the spouse, son, or daughter of an individual who has
committed or conspired to commit a human trafficking offense
in the United States or outside the United States and have you NO
within the last five years, knowingly benefited from the
trafficking activities?
Have you knowingly aided, abetted, assisted or colluded with
an individual who has committed or conspired to commit a
NO
severe human trafficking offense in the United States or outside
the United States?
Edit Part 3

Do you seek to engage in espionage, sabotage, export control

violations, or any other illegal activity while in the United NO
States?
Do you seek to engage in terrorist activities while in the United
NO
States or have you ever engaged in terrorist activities?
Have you ever or do you intend to provide financial assistance
NO
or other support to terrorists or terrorist organizations?
Are you a member or representative of a terrorist organization? NO
Have you ever ordered, incited, committed, assisted, or
NO
otherwise participated in genocide?
Have you ever committed, ordered, incited, assisted, or
NO
otherwise participated in torture?
Have you committed, ordered, incited, assisted, or otherwise
participated in extrajudicial killings, political killings, or other NO
acts of violence?
Have you ever engaged in the recruitment or the use of the
NO
child soldiers?
Have you, while serving as a government official, been
responsible for or directly carried out, at any time, particularly NO
severe violations of religious freedom?
Have you ever been directly involved in the establishment or
enforcement of the population controls forcing a woman to
NO
undergo an abortion against her free choice or a man or a
woman to undergo sterilization against his or her free will?
Have you ever been directly involved in the coercive
NO
transplantation of human organs or bodily tissue?
Edit Part 4

Have you ever sought to obtain or assist others to obtain a

visa, entry into the United States, or any other United States
NO
immigration benefit by fraud or willful misrepresentation or
other unlawful means?
Edit Part 5

Have you ever withheld custody of a U.S. citizen child outside

the United States from a person granted legal custody by a U.S. NO
court?
Have you voted in the United States in violation of any law or
NO
regulation?
Have you ever renounced United States citizenship for the
NO
purpose of avoiding taxation?

Edit Location Information

Location where you will be submitting your application
Current Location: MUMBAI, INDIA