Please add page while required .

1. What is the purpose of your trip?

2. Full Name (As in Passport) & Passport Number
• Have you ever used other names (i.e. maiden, religious, professional etc.)

3. Marital Status. (Married/Single/Widowed/Divorced/Separated)

4. National Identification Number. (If Applicable)
• Do you hold or have you held any nationality other than the one indicated? (Give the Nationality & Passport No.)
•Are you a permanent resident of a country/region other than your country/region of origin (nationality) indicated above?

• U.S. Social Security Number. (If Applicable)

• U.S. Taxpayer ID Number. (If Aoolicable)
5. Home Address (Present) & Mailing Address.

6. 2 Contact Numbers. (Personal/Home/Business)

7. Valid E-Mail Address mandatory.
8. Have you ever lost a passport or had stolen. (Explain with Passport number)
9. When do you intend to arrive in the U.S.?
10. How long do you intend to stay in the U.S.?
11. At what address will you stay in the U.S.?

12. Who will pay for your trip? Give the Name, Relation, Address & Phone Number.

13. Names and relationships of persons traveling with you. (If Applicable)

14. Have you ever been in the U.S.? When (Date of Arrival), for how long? (Last five U.S. visit)
Arrival date- I I ; Length of stay _ Arrival date- I I ; Length of stay _
Arrival date- I I ; Length of stay _ Arrival date- I I ; Length of stay _
Arrival date- I I ; Length of stay _
• U.S. Drivers license Number and State of Drivers license. (If Applicable)
15. Have you ever been issued a U.S. visa? (If YES give Date last visa was Issued, visa class and
Visa Number (8 digits)
16. Have you ever been Lost/refused/cancelled/revoked a U.S. visa? When? Where? What type of
Visa? (If Applicable)
• Has anyone ever filed an immigrant petition on your behalf with the United States Citizenship and Immigration Services?
Explain
*Are you or have you ever been a U.S. leaal permanent resident?
17. Full Name and Address And Relationship of Contact Person or Organization in the U.S. (Include
Zip code, Telephone Number and E-mail)

18. Father's Full Name and Date of Birth.

19. Mother's Full Name and Date of Birth.
20. Are any of the following persons in the U.S.? (Father/Mother, Son/Daughter, Husband/Wife,
Brother/Sister, Fiance Fiancee). If YES gives the Name, Relation and status. (i.e. LPR, U.S. citizen,
studying, working etc.)

• Do you have any other relatives in the United States? Yes/No

21. Spouse Full Name, Place & Date of Birth. (If Applicable)
22. Name, Address and phone number of Present Employer/Business/School/College/University &
provide Job start date./Business start date./Study start date.

23. Monthly Income/Salary in local currency & Designation.

24. Provide your employment information for the last FIVE years, if Applicable. Give last two Employer
Name, Address, Telephone number, Job Title, Supervisor's Name, dates of Employment (dd/mm/yyyy -
dd/mm/yyyy).

25. List all educational institutions you attend or have attended (If Applicable).
Give the Name of Institutions, Address, Course of S”tudy and Duration: Start to End (dd/mm/yyyy)

26. Provide a List of Languages You Speak (Language name).

27. List All Countries you have entered in the last Five Years (Country Names only).

28. List all Professional, Social and Charitable Organizations to which you belong.

29. Do you have a social media presence? social Media Provider/Platform

(1): Facebook/Instagram/Twitter/LinkedIn/YouTube or any other social media?

Social Media Identifier:

Have you used additional social media platforms in the last five years?

30. Have you used any other email addresses in the last five years?

Have you used any other phone numbers in the last five years?