Personal, Address, Phone, and Passport Information
Name Surname:
Full Name in Native Language:
Other Names Used:
Sex:
Marital Status:
Date of Birth:
Place of Birth :
Nationality:
Other Nationalities:
National Identification Number: voter id:
U.S. Social Security Number:
U.S. Taxpayer ID Number:
Home :
City:
State/Province:
Postal Zone/ZIP Code:
Country:
Same Mailing Address?:
Home Phone Number:
Work Phone Number:
Work Fax Number:
Mobile/Cell Phone Number:
Email Address:
Passport Nnumber :
Passport Book Number :
Country / Authority that issued :
City Where Issued :
State / Province Where Issued :
Country Where Issued :
Issuance Date :
Expiration Date :
Have you ever lost a passport or had one stolen?
Specific Travel Plan?
Intended Date of Arrival:
Intended Length of Stay in U.S.:
Address where you will stay in the U.S:
Person/Entity Paying for Your Trip:
Other Persons Travelling with You:
Surname of the persons travel
with you
Contact Person Name in the U.S.
Organization Name OR Company name in the U.S.:
Relationship to You:
U.S. Contact Address:
Phone Number:
Email Address:
Family Information
Father's 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.?
Do you have any immediate relatives, not
Giving name of the persons
travel with you
Have you ever been in the U.S.?
If yes.....
Intended Date of Arrival:
How long did you stay in the state……
Have you ever been issued a U.S. visa?
If yes then date of issued visa………………
Visa number
Have you ever been refused a U.S. Visa, been
refused admission to the United States, or
withdrawn your application for admission at
the point of entry?
If yes explain Yes and reasons was
unexplained.
U.S. Contact Information
including parents in the U.S.?
Do you have any other relatives in the United States?
SPOUSE
SPOUSE Surname:
given name:
Spouse date of birth:
Spouse place of birth:
Work / Education / Training Information
Primary Occupation:
Specify Other:
Present Employer or School Name:
Address:
City:
State/Province:
Postal Zone/Zip Code:
Country:
Month Salary in Local Currency:
Briefly Describe your Duties:
Were you previously employed?
Name of the Company:
Address:
Telephone:
Position:
Start Date:
End Date:
Supervisor’s Surname:
Supervisor’s giving name:
Briefly Describe your Duties
▲ Have you attended any
educational institutions other
than elementary schools? yes
Name of Institution (1) :
Address of Institution:
City:
State/Province:
Postal Zone/ZIP Code:
Country:
Course of Study:
Date of Attendance From:
Date of Attendance To:
Do you belong to a clan or tribe?
Clan or Tribe Name:
▲ HAVE YOU TRAVELLED TO ANY
COUNTRIES WITHIN THE LAST FIVE
YEARS?
Countries Visited:
Have you belonged to, contributed to, or
worked for any professional, social, or
charitable organization? If yes The
organization name:
