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Nonimmigrant Visa - Confirmation Page

Online Nonirmnigrant Visa Application (DS- 160)

Confirmation
This confirms the submission of the Nonimmigrant visa application for:
Name

MOISEI, PARASCOVIA
I

Provided:

Photo not Frouid ed

Date Of Birth: 27 oCT 1990 BAIMACLIA, MOLDOVA Place of Birth: Gender: Nationality: Passport Number:
Purpose of Female
MOLDOVA

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Location Selected:

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A2752664
TOURISM/MEDICAL
TREATMENT (82)

cHs Embassy of the United States of America

1O3 Mateevici Street

Travel:
Completed
On:

Chisinau MD-2OO9 Republic of Moldova

Version 01.01.03

07 MAR 2012 AAOO26TTCL

Confirmation
No:

THIS TS NOT A VLqA

YOU MUST BRING this confirmation page and the following document(s) with you to the Application Service Center:

Passport
You may also provide any additional documents you feel will support your case.

yOU MUST SUBMIT this confirmation page with a clear and legible barcode at the time of your interview. If you do not have access to a printer atthis time, select the option to email your conflrmation page to an email address. You may print or email your application for your own records. YOU DO NOT need to submit the application at the time of the interview. please note that you will be required to provide proof that you have paid the visa application fee and any other fees associated with your application. There may be other fees associated with the visa application process. Please check your country's Reciprociw Schedule for any other fees you may owe.

Ifyouhavefurtherquestions,ortofindoUthowtocontacttheConsularPost,pleasegoto@or
http : //travel.state.oov
.

@ittedwithyourvisaapplicationdidnotmeetthequalitystandardSspecifiedintheinstrUctionson photo guideline instructions on

submission ior visa applicants. Please have new photos taken, specifically following the
NOTE: Unless exempt from an interview, you will be required to sign your application by providing a biometric signature, i.e' your fingerprint before a consular officer, By pioviding this biometric signature you are certifying under penalty of perjury that you have

read and understood the questions in your nonimmigrant visa application and that all statements that appear in your nonimmigrant visa application have been made by you and are true and complete to the best of your knowledge and belief.. Furthermore at the time of your interview, you will be required to certify under penalty of perjury that all statements in your application and those made during your interview are true and compete to the best of your knowledge and belief.

ttps://ceac.state.gov/GENNIV/general/esign/complete-done.aspx?node=Done

Consular Electronic Application Center - Print Application

Online Noninnnigrant Visa Applbation (DS- 160)

Applic ation

- Sensitiv'e But Unc

lassified( SBU)

Only print this application for your records. You will not be permitted to submit a printed copy of your application during your interview process.

Photo Provided:

Fhoto nst Frocided

Confirmation Number:
r

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MOISEI, PARASCOVIA
DOES NOT APPLY
NO NO FEMALE

Personal, Address, Phone, and Passport/Travel Document Information

Name Provided:
Full Name in Native Language:

Other Names Used: Telecode Name Used: Sex: Marital Status: Date of Birth:
Place of Birth:

SINGLE

27 oCTOBER 1990 BAIMACLIA, CANTEMIR, MOLDOVA

MOLDOVA
NO

Nationality: Other Nationalities: National Identification Number:

U.S. Social Security Number:

DOES NOT APPLY DOES NOT APPLY DOES NOT APPLY S.BAIMAC LIA R,CANTEMIR BAIMACLIA
CANTEMIR

U.s. Taxpayer ID Number;

Home Address: CitY:

State/Province:
Postal ZonelZIP Code:
C

DOES NOT APPLY

MOLDOVA
YES

ountry:

Same Mailing Address?

Primary Phone Number:

Secondary Phone Number:
ttps:/lceac.state.gov/GENNIV/commonlprintapplication.aspx?P'l

27343420
DOES NOT APPLY
Hr0dJwcnnROkwztqqlMWOMOxukFd

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Work Phone Number:
Email Address:

Consular Electronic Application Center - Print Application

DOES NOT APPLY pashuta 15@yahoo.com

:

Passpoftrlravel Document Type

REGULAR

Passpoffiravel Document Number:

Passport Book Number:
C

42752664
DOES NOT APPLY
MOLDOVA

ountry/Authority that Issued Passport/travel Docume nt: City Where Issued: Country Where Issued:
Issuance Date: Expiration Date:

CANTEMIR
MOLDOVA

28 DECEMBER 2006 28 DECEMBER 2016

NO

Have you ever lost a passport or had one stolen?

Travel Information

i{ fnu List of Purposes of Trip to the U.s.

Purpose of Trip to the U.S. (1):
TEMP. BUSINESS PLEASURE VISITOR (B)

Specify:

TOURISM/MEDICAL TREATMENT (B2)

Intended Date of Arrival: Intended Length of Stay in U.S.:

Address where you will stay in the U.S.:

07 MAY 2012 2 WEEK(S)

23.30 31 AVENUE
ASTORIA, NEW YORK 11106
SELF
YES NO

City, State, Postal/Zip Code:

Person/Entity Paying for Your Trip: Are there other persons traveling with you?

Are you traveling as part of a group or organization?

id P.rront Traveling with You:

Name (1): Relationship to You: Name (2): Relationship to You:
MOISEI, VASILE
PARENT

MOISEI, ANA
PARENT

fd nur" you ever been

Date Arrived (1):
Length of Stay:

in the u.s.?

YES

Provide information on your last five U.S. visits:

09 JUNE 2011

3 MONTH(S)
NO YES

Do you or did you hold a U.S. Driver's License?

l{ nur" you ever been issued a U.S. Visa?

Date Last Visa was Issued: Visa Number:

18 MAY 2011
E3568743
NO YES

Are you applying for the same type of visa?

Are you applying in the same country where the visa above is issued and is this country your principal country of residence?
Have you been ten-printed? Has your U.S. Visa ever been lost or stolen?

NO NO

ttps:/lceac.state.gov/GENN|V/common/printapplication.aspx?Pl HOdJwcnnROkwztqqlMWOMOxukFd...

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Consular Electronic Application Center - Print Application

Has your U.S. Visa ever been cancelled or

revoked?

NO NO

Have you ever been refused a U.S. Visa, been refused admission to the United States, or withdrawn your application for admission at the port of entry?
Has anyone ever filed an immigrant petition on your behalf with United States Citizenship and Immigration Services?

the

NO

U.S. Contact

Information
CANAZIR DROBENKO, VIORICA
DO NOT KNOW
RELATIVE

U.S.: Organization Name in the U.S.: Relationship to You: U.S. Contact Address:
Contact Person Name in the

23-30 31 AVENUE ASTORIA, NEW YORK 11106

Number: Email Address:

Phone

$46)436-7869
johnandviorica@gmail.com

Family Information

Surnames: Father's Given Names: Father's Date of Birth: Is your father in the U.S.? Mother's Surnames: Mother's Given Names' Mother's Date of Birth: Is your mother in the U.S.?
Father's
Do you have any immediate relatives, not including parents in U,S.? Do you have any other relatives in the United

MOISEI VASILE

05 APRIL 1965
NO

MOISEI
ANA

14 IULY 1969
NO

the

NO

States?

YES

Work/ Education/Tra ining Information

Primary

Occupation: Name:

STUDENT

Present Employer or School

UNIVERSITATEA LIVERA INTERNATIONALA DIN MOLDOVA ULIM ANUL 3 DE STUDII

AddTesS: City: State/Province: Postal ZonelZip Code: Countryr Work Phone Number:
Monthly Salary in Local Currency (if

52 VLAICU PARCALAB STREET

CHISINAU DOES NOT APPLY MD-2012
MOLDOVA

22220029

employed):

DOES NOT APPLY

STUDENT AT SCHOOL

Briefly Describe your

Duties:

Security and Background Information

Do you have a communicable disease of public health significance? (Communicable diseases of public significance include chancroid, gonorrhea, granuloma inguinale, infectious leprosy, lymphogranuloma venereum, infectious stage syphilis, active tuberculoiis, and others diseases as determined by the Department of Health and Human Services.) Do you have a mental or physical disorder that poses or is likely to pose a threat to the safety or welfare yourself or others?
ttps://ceac.state.gov/GENNIV/common/printapplication.aspx?Pl HOdJwcnnROkWztqqlMWOMOxukFd. ..
NO

of

No

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other similar action?

Consular Electronic Application Center - Print Application

NO NO

Are you or have you ever been a drug abuser or addict? Have you ever been arrested or convicted for any offense or crime, even though subject of a pardon, amnesty, or Have you ever violated, or engaged in a conspiracy to violate, any law relating to controlled substances?

NO NO

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?
Have you ever been involved in, or do you seek to engage in, money laundering?

NO NO

Have you ever committed or conspired to commit a human trafficking offense in the United States or outside the United 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 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 severe human trafficking offense in the United States or outside the United States? Do you seek to engage in espionage, sabotage, export control violations, or any other illegal activity while in the United States? Do you seek to engage in terrorist activities while in the United States or have you ever engaged in terrorist activities?

NO

NO

NO

NO

Have you ever or do you intend to provide financial assistance or other support to terrorists or terrorist organizations?

NO

Are you a member or representative of a terrorist organization?

Have you ever ordered, incited, committed, assisted, or otherwise participated in genocide? Have you ever committed, ordered, incited, assisted, or otherwise participated in torture?
Have you committed, ordered, incited, assisted, or otherwise participated in extrajudicial killings, political killings,

NO NO NO NO

or other acts of violence?

Have you ever engaged in the recruitment or the use of the child soldiers?
Have you, while serving as a government official, been responsible for or directly carried out, at any time,
NO NO

particularly severe violations of religious freedom?

Have you ever been directly involved in the establishment or enforcement of the population controls forcing a woman to undergo an abor[ion 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 transplantation of human organs or bodily tissue? Have you ever been the subject of a removal or deportation hearing? Have you ever sought to obtain or assist others to obtain a visa, entry into the United States, or any other United States immigration benefit by fraud or willful misrepresentation or other unlawful means? Have you failed to attend a hearing on removability or inadmissibility within the last five years?
Have you ever been unlawfully present, overstayed the amount of time granted by an immigration official or otherwise violated the terms of a U.S. visa? 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. court? Have you voted in the United States in violation of any law or regulation?
NO

NO NO NO

NO NO

NO

NO NO NO

Have you ever renounced United States citizenship for the purpose of avoiding taxation? Have you attended a public elementary school on student (F) status or a public secondary school after November 30, 1996 without reimbursing the school?

Location Information
Location where you will be submitting your application

Current Location:

CHISINAU, MOLDOVA

Preparer of Application
ttps://ceac.state.gov/GENNIV/common/printapplication.aspx?Pl Hr0dJwcnnRokWztqqlMWOMOxukFd..
.

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Preparer Surnames: Preparer Given Names: Organization Name: Street Address:
C

Consular Electronic Application Center - Print Application

Did anyone assist you in filling out this application?

YES

DROBENKO JOHN

DOES NOT APPLY

23.30 31 AVENUE
ASTORIA

itY:
r

State/Province

NEW YORK

Postal ZonelZIP Code:

11106 UNITED STATES OF AMERICA

RELATIVE

Country:
Relationship to You:

You electronically Signed your application on 07-Mar-20t2 09:49:46. You were required to electronically sign your application

yourself, unless otherwise exempt by regulaUon, even if the application was prepared by someone other than yourself. Your electronic signature certifies that you have read and understood the questions in this application and that your answers are true and correct to the best of your knowledge and belief. The submission of an application containing any false or misleading statements may result in the permanent refusal of a visa or the denial of entry into the United States. All declarations made in this application are unsworn declarations made under penalty of perjury. (28 U.S.C. 1746).

The information that you have provided in your application and other information submitted with your application may be accessible to other government agencies having statutory or other lawful authority to use such information, including for law enforcement and immigration law enforcement purposes. The photograph that you provide with your application may be used for employment verification or other U.S. law purposes.

ttps://ceac.strate.gov/GENNIV/common/printapplication.aspx?Pl

HildJwcnnROkWztqqlMWOMOxukFd...

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