E-2 Visa Application Form

PAGE 1
1 Surname:
(All surnames listed in your passport)
2 Given Names:

3 Full Name in Native Alphabet:

Have you ever used any other names?
4 N/A
Maiden, religious, professional, etc.
5 Sex: Male Female
Married Common Law Civil Union
Marital Status:
6 Single Widowed Divorced
Legally Separated Other (details):
Birth Information
Enter information as shown in your passport
Date (DD-MMM-YYYY):
7
City:
Province / State:
Country:

PAGE 2
8 Nationality:
Do you hold or have you held any
9 nationality other than the one indicated N/A
above? If so, where?
Are you a permanent resident of a
10 country / region other than the country N/A
listed as your nationality?
11 National Identification Number:
(ex. SIN card number)

12 U.S. Social Security Number: N/A

13 U.S. Taxpayer ID Number: N/A

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 PAGE 3
14 Have you made specific travel plans? YES NO
15 Intended / estimated date of travel:

PAGE 5
Have you ever been in the U.S.A? YES NO
Date (DD-MMM-YYYY):
Length of stay:
Date (DD-MMM-YYYY):
Length of stay:
16
Date (DD-MMM-YYYY):
Length of stay:
Date (DD-MMM-YYYY):
Length of stay:
Date (DD-MMM-YYYY):
Length of stay:
Do you, or did you ever hold a U.S.
drivers license? YES NO
17 License Number:
State of License:
(8-digit number displayed in red on the lower right-hand side of your visa. If your
Have you ever been issued a U.S. Visa? previous visa was a border crossing card, enter the last 12-digit number of the first line
of the machine-readable zone)

18
Don’t know
Date (DD-MMM-YYYY):
Visa Number:

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 SKIP THIS BOX OF QUESTIONS IF
THIS IS YOUR FIRST VISA
APPLICATION
Are you applying for the same visa type?

Are you applying from the same country

the visa above was issued, and is this
your place of principal residence?
19
Have you been ten-printed?
(fingerprinted – all 10 digits)

Has your U.S. visa ever been lost or

stolen?
Has your U.S. visa ever been cancelled
or revoked? If yes, Explain:
(Verify this with previous employer if applicable)
Have you ever been refused a U.S. visa,
or been refused admission to the United
20
States, or withdrawn your application for
admission at the port of entry?
Has anyone ever filed an immigrant
petition on your behalf with the United
21
States Citizenship and Immigration
Services?

PAGE 6
Home Address
Street address:
City:
22
Province:
Postal Code:
Country:
Is your mailing address the same as your
home address? YES NO If no, provide mailing address:
Street address:
23 City:
Province:
Postal Code:
Country:

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 Primary Phone Number:
24 Secondary Phone Number:
Work Phone Number:
List all other phone numbers used in the
25
last 5 years:
26 Main Email Address:

-
-
List all other email addresses used in the
27 -
last 5 years, including work emails:
-
-
Platform:
List all social media accounts used in Identifier:
the last five years:
Platform:
Enter apps and websites that you use to Identifier:
collaborate, share information, and interact with
others. List the username, handle, screenname, or Platform:
other identifiers associated with your social media Identifier:
28 profile. (You do not need to list accounts designed
for use by multiple users within a business or Platform:
other organization.) Identifier:
Platform:
Facebook, Google+, Instagram, Linkedin, Identifier:
Pintrest, Reddit, Tumblr, Vine, Youtube, etc.
Platform:
Identifier:

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29 Passport Information Submit image of passport ID page (both sides of the book)

Have you ever lost a passport or had one

stolen? YES NO If yes, provide the following:

30 Passport document number:

Country / Authority that issued:
Explain:

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 Page 9
Father of Applicant
Surname:
Given Name:
31
D.O.B. (DD-MMM-YYYY):
Is your father in the U.S.? YES NO
If yes, what is the status? U.S. Citizen P.R. Non-immigrant Other
Mother of Applicant
Surname:
Given Name:
32
D.O.B. (DD-MMM-YYYY):
Is your mother in the U.S.? YES NO
If yes, what is the status? U.S. Citizen P.R. Non-immigrant Other
Do you have any immediate relatives,
not including parents in the United YES NO
States?
Surname:
33
Given Name:
Relationship to you? Spouse Fiancé Child Sibling
What is the relative’s status? U.S. Citizen P.R. Non-immigrant Other
Do you have any other relatives in the
34 YES NO
United States?

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 PAGE 10
Spouse of Applicant N/A
Surname (include maiden name):
Given Name:
D.O.B. (DD-MMM-YYYY):
Nationality:
Place of Birth
City:
35
Country:
Spouses Current Address Same as Home Mailing Other (specify below)
Street address:
City:
Province:
Postal Code:
Country:

PAGE 11
36 Start Date (DD-MMM-YYYY):

37 Monthly Income in Local Currency:

PAGE 12
38 Were you previously employed? YES NO

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 Previous Employer #1
Employer Name:
Street Address:
City:
State / Province:
Postal Code / Zip Code:
Country:
39 Phone Number:
Job Title:
Supervisors Surname:
Supervisors Given Names:
Employment Start (DD-MMM-YYYY):
Employment End (DD-MMM-YYYY):
Brief description of duties:

Previous Employer #2
Name:
Street Address:
City:
State / Province:
Postal Code / Zip Code:
Country:
40 Phone Number:
Job Title:
Supervisors Surname:
Supervisors Given Names:
Employment Start (DD-MMM-YYYY):
Employment End (DD-MMM-YYYY):
Brief description of duties:

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 High School
High School Name:
Street Address:
City:
State / Province:
41
Postal Code / Zip Code:
Country:
Course of Study: Academic
Start (DD-MMM-YYYY):
End (DD-MMM-YYYY):
Other Post-Secondary
Name:
Street Address:
City:
State / Province:
42 Postal Code / Zip Code:
Country:
Major / Course of Study:
Certificate / Degree / Diploma Title:
Start (DD-MMM-YYYY):
End (DD-MMM-YYYY):
Other Post-Secondary
Name:
Street Address:
City:
State / Province:
43 Postal Code / Zip Code:
Country:
Major / Course of Study:
Certificate / Degree / Diploma Title:
Start (DD-MMM-YYYY):
End (DD-MMM-YYYY):
PAGE 13

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44
Do you belong to a clan or tribe? YES NO
If yes, what is the name?
45
-
List the languages you speak: -
-
46
YES NO
Have you traveled to any countries or
If yes, provide a list:
regions in the last five years?

47
Have you belonged to, contributed to, or YES NO
worked for any professional, social, or If yes, provide a list:
charitable organization?
48
Do you have any specialized skills or YES NO
training, such as firearms, explosives,
nuclear, biological, or chemical If yes, Explain:
experience?
49
Have you ever served in the military? YES NO If yes, provide the following:
Country:
Branch of Service:
Rank/Position:
Military Specialty:
Start (DD-MMM-YYYY):
End (DD-MMM-YYYY):
50
Have you ever served in, been a member YES NO
of, or been involved with a paramilitary
unit, vigilante unit, rebel group, guerrilla If yes, Explain:
group or insurgent organization?

PAGE 14

YES NO
Do you have a communicable disease of
51 If yes, Explain:
public health significance?

Do you have a mental or physical YES NO

disorder that poses, or is likely to pose a
52
threat to the safety or welfare of yourself If yes, Explain:
or others?

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 Are you, or have you ever been a drug
53 YES NO
abuser or addict?

PAGE 15

Have you ever been arrested or convicted for any offense or crime, even
54 YES NO
though subject of a pardon, amnesty, or other similar action?

Have you ever violated, or engaged in a conspiracy to violate any law relating
55 YES NO
to controlled substances?
Are you coming to the United States to engage in prostitution or unlawful
56 commercialized vice, or have you been engaged in prostitution or procuring YES NO
prostitutes within the past 10 years?
Have you ever been involved in, or do you seek to engage in money
57 YES NO
laundering?

Have you ever committed or conspired to commit a human trafficking

58 YES NO
offense?
Have you ever knowingly aided, abetted, assisted, or colluded with an
59 individual who has committed or conspired to commit a sever human YES NO
trafficking offense?
Are you the spouse, son, or daughter of an individual who has committed or
60 conspired to commit a human trafficking offense, or have you knowingly YES NO
benefited from human trafficking activities in the last 5 years?
PAGE 16

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

61 YES NO
any other illegal activity while in the United States?

Do you seek to engage in terrorist activities while in the United States, or have
62 YES NO
you ever engaged in terrorist activities?

Have you ever, or do you intend to provide financial assistance or other

63 YES NO
support to terrorists or terrorist organizations?

64 Are you a member or representative of a terrorist organization? YES NO

Are you the spouse, son, or daughter of an individual who has engaged in
65 terrorist activity, including providing financial assistance or other support to YES NO
terrorists or terrorist organizations in the past 5 years?
Have you ever ordered, incited, committed, assisted, or otherwise
66 YES NO
participated in genocide?

Have you ever committed, ordered, incited, assisted, or otherwise

67 YES NO
participated in torture?

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 Have you committed, ordered, incited, assisted, or otherwise participated in
68 YES NO
extrajudicial killings, political killings, or other acts of violence?

69 Have you ever engaged in the recruitment or the use of child soldiers? YES NO

Have you, while serving as a government official, been responsible for, or

70 YES NO
directly carried out, particularly severe violations of religious freedom?
Have you ever been directly involved in the establishment of enforcement of
population controls forcing a woman to undergo an abortion against her free
71 YES NO
choice, or forcing someone to undergo sterilization against his or her free
will?
Have you ever been directly involved in the coercive transplantation of human
72 YES NO
organs or bodily tissue?

PAGE 17

73 Have you ever been the subject of a removal or deportation hearing? YES NO
Have you ever sought to obtain or assist others to obtain a visa, entry into the
74 United States, or any other United States immigration benefit by fraud or YES NO
willful misrepresentation or other unlawful means?
Have you failed to attend a hearing on removability or inadmissibility in the
75 YES NO
last 5 years?
Have you ever been unlawfully present, overstayed the amount of time
76 granted by an immigration official, or otherwise violated the terms of a U.S. YES NO
visa?
77 Have you ever been removed or deported from any country? YES NO

PAGE 18

Have you ever withheld custody of a U.S. citizen child outside the United
78 YES NO
States from a person granted legal custody by a U.S. court?

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

Have you ever renounced United States citizenship for the purposes of
80 YES NO
avoiding taxation?
Have you attended a public elementary school on student (F) status or a
81 public secondary school after November 30, 1996, without reimbursing the YES NO
school?

PAGE 19
Current Employer
82 Employer Name: COPPER TIP ENERGY SERVICES INC
Years with Present Employer:

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 Street Address: 1101 11 AVE
City: NISKU
Province: ALBERTA
Postal Code: T9E 0S1
Country: CANADA
Highest Level of Education
School:

83 Degree:
Major:
Year:
Do you have any other relevant YES NO
84 education to report?
If yes, Explain:

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