Personal Information 1

Surnames: Pelayo
Given Names with Middle Names: Almina Detiquez
Full Name in Native Alphabet: Almina Detiquez Pelayo

Q: Have you ever used other names (i.e., maiden, religious, professional, alias, etc.)?
A: Yes or No: No

Q: Do you have a telecode that represents your name?

A: Yes or No: No

Sex: Female
Marital Status: Single

Date and Place of Birth

Date: October 30, 1978
Month: October
Year: 1978
City: Candaba
Province: Pampanga
Country: Philippines

Personal Information 2

Country/Region of Origin (Nationality):

Q: Do you hold or have you held any nationality other than the one indicated above on nationality?
A: Yes or No: No

Q: Are you a permanent resident of a country/region other than your country/region of origin (nationality) indicated above?
A: Yes or No: No

National Identi cation Number:

U.S. Social Security Number:
U.S. Taxpayer ID Number:

Travel Information

Purpose of Trip to the U.S.: Tourist/Business (B1/B2)

Q: Have you made speci c travel plans?

A: Yes or No:
IF YES
Provide a complete itinerary for your travel to the U.S.
Date of Arrival in U.S.:
(Format: DD-MMM-YYYY)
Arrival Flight (if known):
Arrival City:
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Date of Departure from U.S.:
(Format: DD-MMM-YYYY)
Departure Flight (if known):
Departure City:

Provide the locations you plan to visit in the U.S.

Location:

IF NO
Intended Date of Arrival
Date: December 15, 2023
Month: December
Year: 2023
Intended Length of Stay in U.S.: 2 weeks

Address Where You Will Stay in the U.S.

Street Address: 5715 Harold way Apt 107
City: Los Angeles
State: California
ZIP Code (if known): 90028

Person/Entity Paying for Your Trip

SELECT ONE: SELF, OTHER PERSON, PRESENT EMPLOYER, EMPLOYER IN THE U.S., OTHER COMPANY/
ORGANIZATION
A: Self

Travel Companions Information

Persons traveling with you

Q: Are there other persons traveling with you?
A: Yes or No: Yes

Q: Are you traveling as part of a group or organization?

A: Yes or No: No

Enter person(s) traveling with you

Surnames of Person Traveling With You: Pelayo
Given Names with Middle Names of Person Traveling With You: Allyssa Mira
Relationship with Person
SELECT ONE: PARENT, SPOUSE, CHILD, OTHER RELATIVE, FRIEND, BUSINESS ASSOCIATE, OTHER
A: Child

Previous U.S. Travel Information

Q: Have you ever been in the U.S.?
A: Yes or No: No
YES
Provide information on your last ve U.S. visits:
Date Arrived
Date:
Month:
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Year:
Lenght of Stay:

Q: Have you ever been issued a U.S. Visa?

A: Yes or No: No
YES
Previous U.S. Visas
Date Last Visa Was Issued
Date:
Month:
Year:
Visa Number:

Q: Are you applying for the same type of visa?

A: Yes or No:

Q: Are you applying in the same country or location where the visa above was issued, and is this country or location your
place of principal of residence?
A: Yes or No:

Q: Have you been ten-printed?

A: Yes or No:

Q: Has your U.S. Visa ever been lost or stolen?

A: Yes or No:

Q: Has your U.S. Visa ever been cancelled or revoked?

A: Yes or No:

Q: Have you ever been refused a U.S. Visa, or been refused admission to the United States, or withdrawn your application
for admission at the port of entry?
A: Yes or No:

Q: Has anyone ever led an immigrant petition on your behalf with the United States
Citizenship and Immigration Services?
A: Yes or No:

Address and Phone Information

Home Address
Street Address: Emerald st, Villas De Magdalena
City: San Miguel
State/Province: Bulacan
Postal Zone/ZIP Code: 3011
Country/Region: Philippines

Mailing Address
Q: Is your Mailing Address the same as your Home Address?
A: Yes or No: Yes

Phone
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 Primary Phone Number: 09754143606
Secondary Phone Number: 09771556113
Work Phone Number:

Q: Have you used any other phone numbers in the last ve years?
A: Yes or No: Yes

Email Address: allyssamirapelayo@gmail.com

Q: Have you used any other email addresses in the last ve years?
A: Yes or No: No

Social Media
Social Media Provider/Platform: Facebook
Social Media Identi er: Mina Pelayo

Q: Do you wish to provide information about your presence on any other websites or applications you have used within the
last ve years to create or share content (photos, videos, status updates, etc.)?
A: Yes or No: Yes

Passport Information
Passport/Travel Document: REGULAR
Passport/Travel Document Number: P1950114B
Passport Book Number: P1950114B
Country/Authority that Issued Passport/Travel Document: Philippines

Where was the Passport/Travel Document Issued?

City: Malolos
State/Province *If shown on passport:
Country/Region: Philippines

Issuance Date/Month/Year: 14-06-2019

Expiration Date/Month/Year: 13-06-2029
Q: Have you ever lost a passport or had one stolen?
A: Yes or No: No

U.S. Point of Contact Information

Contact Person
Surnames: Pelayo
Given Names with Middle Names: Mayla Detiquez
Organization Name:

Relationship to You
SELECT ONE: RELATIVE, SPOUSE, FRIEND, BUSINESS ASSOCIATE, EMPLOYER, SCHOOL OFFICIAL, OTHER
A: Relative

Address and Phone Number of Point of Contact

U.S. Street Address: 5715 Harold Way Apt 107
City: Los Angeles
State: California
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ZIP Code (if known): 90028
Phone Number: 3107390823
Email Address: pelayomayla@yahoo.com

Family Information: Relatives

Father's Full Name and Date of Birth

Surnames: Pelayo
Given Names with Middle Names: Bernardo Dela Cruz
Date of Birth: 20-08-1943
(Format: DD-MMM-YYYY)

Q: Is your father in the U.S.?

A: Yes or No: No
Q: Father's Status
SELECT ONE: U.S CITIZEN, U.S LEGAL PERMANENT RESIDENT (LPR), NON IMMIGRANT, OTHER/I DON'T KNOW
A:

Mother's Full Name and Date of Birth

Surnames: Pelayo
Given Names with Middle Names: Margarita Detiquez
Date of Birth: 20-07-1940
(Format: DD-MMM-YYYY)

Q: Is your mother in the U.S.?

A: Yes or No: No
Q: Father's Status
SELECT ONE: U.S CITIZEN, U.S LEGAL PERMANENT RESIDENT (LPR), NON IMMIGRANT, OTHER/I DON'T KNOW
A:

Q: Do you have any immediate relatives, not including parents, in the United States?
A: Yes or No: Yes
YES
Surnames: Pelayo
Given Names with Middle Names: Mayla Detiquez
Relationship to You
SELECT ONE: SPOUSE, FIANCÉ/FIANCÉE, CHILD, SIBLING
A: Sibling
Relative's Status
SELECT ONE: U.S CITIZEN, U.S LEGAL PERMANENT RESIDENT (LPR), NON IMMIGRANT, OTHER/I DON'T KNOW
A: U.S Citizen

Q: Do you have any other relatives in the United States?

A: Yes or No: Yes

Family Information: Spouse

Spouse's Full Name (include Maiden Name)

Spouse's Surnames:
 Spouse's Given Names with Middle Name:
Spouse's Date of Birth:
(Format: DD-MMM-YYYY)
Spouse's Country/Region of Origin (Nationality):
Spouse's Place of Birth
City:
Country/Region:

Spouse's Address
SELECT ONE: SAME AS HOME ADDRESS, SAME AS MAILING ADDRESS, SAME AS U.S CONTACT ADDRESS, DO
NOT KNOW
IF OTHER:
Street Address:
City:
State/Province:
Postal Zone/ZIP Code:
Country/Region:

Present Work/Education/Training Information

Primary Occupation
SELECT ONE: AGRICULTURE, ARTIST/PERFORMER, BUSINESS,
COMMUNICATIONS, COMPUTER SCIENCE, CULINARY/FOOD SERVICES, EDUCATION,
ENGINEERING, GOVERNMENT, HOME MAKER, LEGAL PROFESSION, MEDICAL/HEALTH,
NATURAL SCIENCE, NOT EMPLOYED, PHYSICAL SCIENCES, RELIGOUS VOCATIONAL,
RESEARCH, RETIRED, SOCIAL SCIENCE STUDENT
IF OTHER PLEASE SPECIFY: Business Owner

Present Employer or School Name: Miracle Shop

Street Address (Line 1): Emerald St, Villas de magdalena
Street Address (Line 2) *Optional:
City: San Miguel
State/Province: Bulacan
Postal Zone/ZIP Code: 3011
Phone Number: 09754143606
Country/Region: Philippines
Start Date/Month/Year:
Monthly Income in Local Currency (if employed and business): 40,000
Brie y describe your duties: Posting of products online like facebook and tiktok application.

Q: Were you previously employed?

A: Yes or No: No

Employer/Employment Information:
Employer Name:
Employer Street Address:
City:
State/Province:
Postal Zone/ZIP Code:
Country/Region:
Telephone Number:
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 Job Title:
Supervisor's Surname:
Supervisor's Given Names with Middle Names:
Employment Date From:
(Format: DD-MMM-YYYY)
Employment Date To:
(Format: DD-MMM-YYYY)
Brie y describe your duties:

Q: Have you attended any educational institutions at a secondary level or above?

A: Yes or No:
Provide the following information on the educational institution(s) you have attended.
Name of Institution:
Street Address:
City:
State/Province:
Postal Zone/ZIP Code:
Country/Region:
Course of Study:
Date of Attendance From:
(Format: DD-MMM-YYYY)
Date of Attendance:
(Format: DD-MMM-YYYY)

Q: Do you belong to a clan or tribe?

A: Yes or No: No

Provide a List of Languages You Speak

Language Name: English
Language Name:

Q: Have you traveled to any countries/regions within the last ve years?

A: Yes or No: Yes
IF YES
Country 1: Hong Kong
Country 2: Taiwan
Country 3:

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

Q: Do you have any specialized skills or training, such as rearms, explosives, nuclear, biological, or chemical
experience?
A: Yes or No: No

Q: Have you ever served in the military?

A: Yes or No: No

Q: Have you ever served in, been a member of, or been involved with a paramilitary unit, vigilante unit, rebel group,
guerrilla group, or insurgent organization?
A: Yes or No: No
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 Security and Background

Q: Do you have a communicable disease of public health signi cance? (Communicable diseases of public signi cance
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.)
A: Yes or No: No

Q: Do you have a mental or physical disorder that poses or is likely to pose a threat to the safety or welfare of yourself or
others?
A: Yes or No: No

Q: Are you or have you ever been a drug abuser or addict?

A: Yes or No: No

Q: Have you ever been arrested or convicted for any offense or crime, even though subject of a pardon, amnesty, or other
similar action?
A: Yes or No: No

Q: Have you ever violated, or engaged in a conspiracy to violate, any law relating to controlled substances?
A: Yes or No: No

Q: Are you coming to the United States to engage in prostitution or unlawful commercialized vice or have you been engaged
in prostitution or procuring prostitutes within the past 10 years?
A: Yes or No: No

Q: Have you ever been involved in, or do you seek to engage in, money laundering?
A: Yes or No: No

Q: Have you ever committed or conspired to commit a human traf cking offense in the United States or outside the United
States?
A: Yes or No: No

Q: Have you ever knowingly aided, abetted, assisted or colluded with an individual who has committed, or conspired to
commit a severe human traf cking offense in the United States or outside the United States?
A: Yes or No: No

Q: Are you the spouse, son, or daughter of an individual who has committed or conspired to commit a human traf cking
offense in the United States or outside the United States and have you within the last ve years, knowingly bene ted from
the traf cking activities?
A: Yes or No: No
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