Visa Application Form

Transcription

1 Photo 5cm x 5cm Visa Application Form! Applicant!s Details (as shown on passport) Surnames Given ames Date of Birth Sex" Marital Status: domestic partnership, married, legally separated, divorced, widowed g g m m a a a a M F " City and State/Province of Birth Country of Birth ationality" Other ationalities Passport umber of Second Citizenship (if applicable) U.S. Social Security umber (if applicable): U.S. Taxpayer ID umber (if applicable): - -. Fiscal Code ational ID umber (if applicable): Home address and/or mailing address (street, town, state/province, zip code, country) Phone Contact umber - Home! Office! Other telephone contact number (mobile phone) + + Address! Passport umber: Passport Book umber (if applicable): Date of Issue: " Expiration Date: " Where was the passport issued/ (City/Country) : g g m m a a a a g g m m a a a a Issuing Country/Authority Has your Passport ever been Lost or Stolen? Si o Passport umber Pass. Issuing Country Indicate if passport was lost or stolen(attach police report) Where When Rev " 1

2 ! Purpose of Trip in the U.S."! Travel Information Intended Date of Arrival? Intended length of stay in the U.S. (mandatory): g g m m a a a a Street Address in the U.S. City (mandatory): State" Zip Code Person/Entity Paying for your Trip in the U.S.:!! Surname and ame / Company " Relationship to ou:" Address " Telephone / ! Contact in the U.S.:!! Surname and ame " Relationship to ou: " Organization ame Address in the U.S.: " City " State" Zip Code (if applicable) Telephone " " Are there any persons travelling with you? If yes, indicate surname, name and relationship to you! Previous U.U. Travel Information:! Provide information on your last 5 visits in the U.S. Have you ever been in the U.S.A.? Date of Arrival Length of Stay () Did you ever hold a U.S. Driving License? 1 Driving License # Issuing State: 2" 3" 4 5 Rev " 2

3 ! Information about Priovious Visas (please attach a copy of your previous U.S. visa) Have you ever been issued a U.S. Visa? " Date of Issue: dd / mm / yyyy Visa umber: " Are you applying for the same type of visa? (printed in red on the visa) Are you applying in the same country or location where the visa above was issued, and is this country or location your place of principal residence? Have you been finger-printed? Has your visa ever been lost or stolen? Has your visa ever been cancelled or revoked? Have you ever been refused a U.S. visa, or been refused admission to the U.S. or withdrawn your application for admission at the port of entry? Has anyone ever filed an immigrant petition on your behalf with the United States Citizenship and Immigration Services?! Contact Information on Relatives Father!s Full ame Date of Birth" Mother!s Full ame " Date of Birth Spouse Full ame (even if divorced)!!! Place and Date of Birth ationality Spouse Address Do you have any immediate relatives in the United States. including parents, brothers, children, spouse, fiancee? Se 1. si, indicarne nome e cognome, grado di parentela e tipo di visto USA 2. Do you have any other relatives living in the United States? Have you traveled to any countries in the last five years? Provide a list of languages you speak Rev " 3

4 ! Work/ Education/ Training Information Present Emplyer or School ame" " Telephone: Address " City" Province " Zip Code Country Monthly Income in Local Currency (if employed) Primary Occupation and Main Duties Provide information about any educational institutions you attended at a secondary level or above ame of Institution Address (at least City, State, Country) Course of Studies and Dates of Attendance From: To: ame of Institution Address (at least City, State, Country)" Course of Studies and Dates of Attendance From: To: Country " Branch of Service Rank/ Position Have you ever served in the military? Military Specialty From: To: Provide your employment information for the last five years that you were employed, if applicable Employer ame Address Previous Position/Duties" from: " to: Employer ame Address Previous Position/Duties" from: " to: Rev " 4

5 ! Provide the following work, education, or training related information. Provide complete and accurate information to all questions that require an explanation Do you belong to a clan or tribe? Have you belonged to, contributed to, or worked for any professional, social, or charitable organization? Do you have any specialized skills or training, such as firearms, explosives, nuclear, biological, or chemical experience? Have you ever served in, been a member of, or been involved with a paramilitary unit, vigilante unit, rebel group, guerrilla group, or insurgent organization?! Provide the following security and background information. Provide complete and accurate information to all questions that require an explanation 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 tuberculosis, and other diseases as determined by the Department of Health and Human Services.) Any disorder that poses or is likely to pose a threat to the safety or welfare of yourself or others? 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 other similar action? Have you ever violated, or engaged in a conspiracy to violate, any law relating to controlled substances? 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? Have you ever committed or conspired to commit a human trafficking offense in the United States or outside the United States? Rev " 5

6 Have you ever 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 U.S? 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 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? Have you ever or do you intend to provide financial assistance or other support to terrorists or terrorist organizations? Are you a member or representative of a terrorist organization? Or have you knowingly benefited from the trafficking activities within the last five years? Have you ever ordered, incited, committed, assisted, or otherwise participated in genocide? Have you committed, ordered, incited, assisted, or otherwise participated in extrajudicial killings, political killings, or other acts of violence? Have you ever engaged in the recruitment or the use of child soldiers? Have you, while serving as a government official, been responsible for or directly carried out, at any time, particularly severe violations of religious freedom? Have you ever been directly involved in the establishment or enforcement of population controls forcing a woman to undergo an abortion 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? Rev " 6

7 Have you failed to attend a hearing on removability or inadmissibility within the last five years? Si o 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 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? Have you ever renounced United States citizenship for the purposes of avoiding taxation? Have you attended a public elementary school on student (F) status or a public secondary school after ovember 30, 1996 without reimbursing the school? Signature Date d d m m y y y y ou understand and agree that American Service Center will handle your information and records only for the necessary visa application process. If you are concerned about the handling of your personal information, please do not mail the forms to us, and submit the application on your own without any use of our services. Continuing use of our services by you following the terms and conditions will mean you accept any and all of our conditions. First and Last ame Passaport# " " " Signature Rev " 7