Online American Visa Application Form

PERSONAL INFORMATION OF PRINCIPAL APPLICANT

Passport Details (as it appears in passport):

Passport Number:

Country/Authority that Issued Passport:

City Where Issued:

Issuance Date:

Expiration Date:

Surname:

Christian Name:

Middle Name:

Alias:

Date of Birth:

City of Birth:

Country of Birth:

Current non-immigrant status in the US?

Home Address including Zip Code:

Home phone number:

Cell phone number:

Email address:

Have you ever lost a passport or had one stolen?
 Yes No

U.S. Social Security Number: (if any)

U.S. Alien Registration Number ("A#"): (if applicable)

Have you made specific plans to travel to the US?
 Yes No

Date of arrival in US:

Arrival Flight

The location(s) you plan to visit in the US:

Address where you will stay in the US:

Do you hold a current US Driver's Licence?

If Yes, Licence Number:

Which state was licence issued:

Have you been ten-printed?
 Yes No

Name of contact person in the US:

Organization name in the US:

Relationship to you:

U.S. Contact address:

U.S. Company phone number:

U.S. Company Fax number:

Your Father’s full name:

Your Father’s date of birth:

Is your father in the U.S.?
 Yes No

Your Mother’s full name:

Your Mother’s date of birth:

Is your mother in the U.S.?

 Yes No

Date of your Marriage:

City, Country of your Marriage:

Have you traveled to any other countries in the last 5 years? If so, please list them:

WORK/EDUCATION/TRAINING INFORMATION for the last 5 years
(If you need more space please submit attachment)

Primary Occupation:

Present Employer or School:

Street Address:

City:

State/Province:

Postal/Zip Code:

Country:

E-mail Address:

Monthly Salary in Local Currency:

Briefly Describe your Duties:

Where were you previously employed?

Employer Name:

Employer Address:

City:

State/Province:

Postal/Zip Code:

Country:

Telephone Number:

Job Title:

Supervisor's Name:

Employment Date from:

Employment Date to:

Briefly describe your duties:

Have you attended any education institutions other than elementary schools?
 Yes No

Name of Institution:

Address of Institution:

City:

State/Province:

Postal/Zip Code:

Course of Study:

Date of Attendance from:

Date of Attendance to:

Name of Institution:

Address of Institution:

City:

State/Province:

Postal/Zip Code:

Course of Study:

Date of Attendance from:

Date of Attendance to:

VISA APPLICATION INFORMATION

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

If yes, please provide details:

Have you belonged to, contributed to, or worked for any professional. Social or charitable organization?
 Yes No

If yes, please provide details:

Do you have a communicable disease of public health significance?
 Yes No

If yes, please provide details:

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?
 Yes No

If yes, please provide details:

Are you or have you ever been a drug abuser or addict?
 Yes No

If yes, please provide details:

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

If yes, please provide details:

Are you coming to the United Sates to engage in prostitution or unlawful commercialized vice or have you been engaged in prostitution within the past 10 years?
 Yes No

Have you or your accompanying family members ever applied for U.S. permanent residence?
 Yes No

If yes, please provide details:

Please list the last five entries into the U.S. including visa type and inclusive dates:
Visa Type 1

From

To

Visa Type 2

From

To

Visa Type 3

From

To

Visa Type 4

From

To

Visa Type 5

From

To

INFORMATION REGARDING SPOUSE (if any)

Passport Details (as it appears in passport):

Issuance Date:

Expiration Date:

Spouse’s Last Name:

Spouse’s First Name:

Spouse’s Middle Name:

Alias:

Date of Birth:

City of Birth:

Country of Birth:

Country of Citizenship:

Current Immigration Status in the U.S.:

Father’s full name:

Father date of birth:

Is your father in the U.S.
 Yes No

Mother’s full name:

Mother’s date of birth:

Is your mother in the US?
 Yes No

Do you have any immediate relatives, not including parents in the U.S.?
 Yes No

INFORMATION REGARDING CHILDREN (IF ANY) (If you need more space please submit attachment)

Name of first child (as it appears in passport):

Passport Number:

Country/Authority that Issued Passport:

City where issued:

Issuance Date:

Expiration Date:

First Child’s Last Name:

First Child’s First Name:

First Child’s Middle Name:

Gender:
 Male Female

Date of Birth:

City of Birth:

Country of Birth:

Country of Citizenship:

Current Immigration Status in the U.S.:

Seconds Child’s Passport Number:

Country/Authority that Issued Passport:

City where issued:

Issuance Date:

Expiration Date:

Second Child’s Last Name:

Second Child’s First Name:

Second Child’s Middle Name:

Gender:
 Male Female

Date of Birth:

City of Birth:

Country of Birth:

Country of Citizenship:

Current Immigration Status in the U.S.:

Third Child’s Passport Number:

Country/Authority that Issued Passport:

City where issued:

Issuance Date:

Expiration Date:

Third Child’s Last Name:

Third Child’s First Name:

Third Child’s Middle Name:

Gender:
 Male Female

Date of Birth:

City of Birth:

Country of Birth:

Country of Citizenship:

Current Immigration Status in the U.S.:

VISA APPLICATION INFORMATION

Have you traveled to any countries within the last 5 year?
 Yes No

If yes, please provide details:

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

If yes, please provide details:

Have you or your accompanying family members ever applied for U.S. permanent residence?
 Yes No

If yes, please provide details: