DS-160 Visa Application Form Questionnaire

DS-160 Visa Application Form Questionnaire

PLEASENOTETHISISALEGALLYBINDINGDOCUMENT.YOUMUSTCOMPLETEALLFIELDSEVENTOSAYTHATYOUDONOTKNOW.THISINFORMATIONWILLBESUBMITTEDTOTHEU.S.GOVERNMENT.

Personal Information 1

Surnames
Given Names
Full Name in Native Alphabet
Have you ever used other names (i.e., maiden, religious, professional, alias, etc.)? / ☐No
☐Yes – Other name (full):
Do you have a telecode that represents your name?
Sex / ☐Male☐Female
Marital status / Choose an item.
Date of birth
City of birth
State/Province of birth
Country of birth

Personal Information 2

Country/Region of Origin (Nationality)
Do you hold or have you held any nationality other than the one indicated above on nationality? / ☐No
☐Yes – Other nationality:
National Identification Number
U.S. Social Security Number
U.S. Taxpayer ID Number

Address and Phone Information

Home Address / Street Address (Line 1)
Street Address (Line 2) *Optional
City
State/Province
Postal Zone/ZIP Code
Country/Region
Mailing Address
☐Same as Home Address above / Street Address (Line 1)
Street Address (Line 2) *Optional
City
State/Province
Postal Zone/ZIP Code
Country/Region
Primary Phone Number
Secondary Phone Number
Work Phone Number
Email Address

Passport Information

Passport/Travel Document Type / Choose an item. /
Passport/Travel Document Number
Passport Book Number
Passport issue Country (citizenship)
Passport issue City name (place of issue)
Passport issue Country (place of issue)
Issue date
Expiry date
Have you ever lost a passport or had one stolen? / Passport number
Passport issue Country (citizenship)
Explain

Travel Information

Have you made specific travel plans? (see below 2 options)
Yes: / Date of Arrival in U.S.
Arrival Flight (if known)
Arrival City
Date of Departure from U.S.
Departure Flight (if known)
Departure City
Provide the locations you plan to visit in the U.S.
No: / Intended Date of Arrival
Intended Length of Stay in U.S.
Address Where You Will Stay in the U.S. / Street Address (Line 1)
Street Address (Line 2) *Optional
City
State/Province
Postal Zone/ZIP Code
Country/Region
Person/Entity Paying for Your Trip? (see below 3 options)
☐Self
☐Other person: / Surnames of the Person
Given Names of the Person
Telephone Number
Email Address
Relationship to You / Choose an item. /
Is the address of the party paying for your trip the same as your Home or Mailing Address? / ☐Yes
☐No – Provide full address of the persona paying for the trip:
☐Other company/Organisation / Name of Company/Organization Paying for Trip
Telephone Number
Relationship to You
Street Address (Line 1)
Street Address (Line 2) *Optional
City
State/Province
Postal Zone/ZIP Code
Country/Region

Travel Companions Information

Are there other persons traveling with you? / ☐No
☐Yes, provide the traveller’s:
Surname
Given Name
Relationship to you
Are you traveling as part of a group or organization? / ☐Yes – Group name:
☐No

Previous U.S. Travel Information

Have you ever been in the U.S.? (see below 2 options)
☐No
☐Yes – Provide details of up to 5 previous trips / 1 Date arrived: / 1 Length of Stay:
2 Date arrived: / 2 Length of Stay:
3 Date arrived: / 3 Length of Stay:
4 Date arrived: / 4 Length of Stay:
5 Date arrived: / 5 Length of Stay:
Do you or did you ever hold a U.S. Driver’s License?(see below 2 options) / ☐No
☐Yes:
License number:
US State of issue:
Have you ever been issued a U.S. Visa?(see below 2 options)
☐No
☐Yes – Provide details / Date Last Visa Was Issued
Visa number
Are you applying for the same type of visa? / ☐Yes ☐No
Are you applying in the same country or location where the above visa was issued, and is the country or location your place of principal of residence? / ☐Yes ☐No
Have you been ten-printed? / ☐Yes ☐No
Have your US visa ever been lost or stolen? / ☐No
☐Yes:
Year:
Details:
Have your US Visa ever been cancelled or revoked? / ☐No
☐Yes:
Details:
Have you ever been refused a US visa? (see below 2 options)
☐No
☐Yes – Provide details / Date
Location
Reason for refusal
Have you ever been refused admission to the US or withdrawn your application for admission at the point of entry? (see below 2 options)
☐No
☐Yes – Provide details / Date
Location
Reason
Have you ever been denied ESTA (electronic system for travel authority) to travel without visa? (see below 2 options)
☐No
☐Yes – Provide details / Date
Location
Reason
Has anyone ever filed a Green card application for permanent residence on your behalf? / ☐No
☐Yes:
Give details:

U.S. Contact Information

Contact Person full name/s
Contact organization
Relationship to you / Choose an item.
Address, phone number and Email address of your contact in US / Street Address (Line 1)
Street Address (Line 2) *Optional
City
State/Province
Postal Zone/ZIP Code
Phone number
Email Address

Family Information

Father’s Full Name (even if deceased)
Father’s Date of Birth
Is your father in the US? / ☐Yes ☐No
Mother’s Full Name (even if deceased)
Mother’s Date of Birth
Is your mother in the US? / ☐Yes ☐No
Do you have any immediate relatives, not including parents, in the United States?(see below 2 options)
☐No
☐Yes:
If more than one person, please provide required information on separate sheet / Surname
Name
Relationship to you
Relative’s status / ☐ US citizen
☐ US legal permanent resident
☐ Non-immigrant resident
☐ Other/do not know
Do you have any other relatives in the United States? / ☐Yes ☐No
If you are married/divorced or separated please give details of your spouse / Name of spouse
Spouse date of birth
City/town of spouse
Country of birth of spouse
Spouse’s full address, if different from applicant’s home address
If divorced give details / Date of marriage
Date of divorce
Reason for divorce
Country marriage was terminated

Work/Education/Training Information

What is your present occupation?
Name and address of employer / Name of employer
Street Address (Line 1)
City
State/Province
Postal Zone/ZIP Code
Phone number
Supervisor’s name and surname
Monthly salary
Brief Job Description
Were you previously employed? (see below 2 options)
☐No
☐Yes
Please give details of any previous employers for the last five years that you were employed
If Self Employed/freelance answer N/A / Employer name
Street Address
City
State/Province
Postal Zone/ZIP Code
Country
Telephone number
Job title
Supervisor’s full name
Employment dates from DD/MM/YYYY to DD/MM/YYYY
Brief Job Description
Please provide details of the school you attended from the age of 14 / Name of institution
Full address
Phone number
Email Address
Attendance dates
Please provide details of any further or higher education establishments attended / Name
Location
Attendance dates
Qualification granted
Do you belong to a clan or tribe? / ☐No
☐Yes:
Give details
Provide a list of languages that you speak:
Please list other countries you have travelled to in the last 5 years
Have you or do you belong to any professional, social or charitable organisations? / ☐No
☐Yes:
Give details:
Do you have any specialised skills or training such as firearms, nuclear, biological or chemical experience? / ☐Yes ☐No
Have you ever served in the military? If yes please give details of branch, rank achieved and dates of service. / ☐Yes ☐No

Security and Background information

If YES- provide details

Do you have a communicable disease of public health significance (such as chancroid, gonorrhoea, granuloma, inguinale, infectious leprosy, lymphogranuloma venerium, infectious stage syphilis, active tuberculosis, and other diseases as determined by the Department of Health and Human Services)?
Do you have a mental or physical disorder that poses a threat to safety or welfare or yourself or others?
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 conspiracy to violate, any law relating to controlled substances?
Are you coming to the US to engage in prostitution or unlawful commercialised vice or have you been engaged in prostitution or procuring prostitutes in the last 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?
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 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?
Do you seek to engage in espionage, sabotage, export control violations, or any other illegal activity while in the US?
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?
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, 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 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 willfulmisrepresentation or other unlawful means?
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?

For temporary work visas

NameofUSEmployer
AddressofUSEmployer
Telephoneno
MonthlySalary
PetitionNo
Nameofperson/company whofiledpetition
HaveyoupreviouslyhadalltenfingerprintstakenbyUS Embassy?
Appointment preferences
I prefer to submit my fingerprints on the following dates
In case the above dates are not available, I cannot go on the following dates

Passport delivery preference

I need my passport delivered to the following address:
(deliveries are done by DX Secure – nominated by the consulate courier service – during working hours; we will notify you of delivery date once known)

Submission of this questionnairecertifiesthatyouhavereadandunderstoodthequestionsinthisapplicationandthatyouranswers aretruetothebestofyourbelief.Thesubmissionofanapplicationcontainingfalseormisleadingstatementsmay resultinpermanentrefusalofavisaordenialofentryintotheUnitedStates.Alldeclarationsmadeinthis applicationareunsworndeclarationsmadeunderpenaltyofperjury,(USU.S.C.1746)

ThisformwillbeelectronicallysubmittedtotheU.S.Embassy,andwillbeconsideredtohavebeenelectronicallysignedbyyou.Insubmittingthisformtous,youarebindingyourselftotheUSregulationsabove,andareacceptingthatanelectronicsignaturehasbeenmadebyyourselfandnotAnyVisa Ltd.

By sending this form for processing Icertifythattheaboveinformationistrueandcompletetothebestofmyknowledgeandunderstandthat insigningthisIamagreeingtothisinformationbeinglegallysubmittedtotheUnitedStatesEmbassyforthe purposeofmakingavisaapplication.Iunderstandthatfailuretodiscloseinformationonthisformmayleadtomy visabeingrefused,andfutureapplicationsbeingrejected.AnyVisa Ltdwillnotberesponsibleforfaultyinformation submittedtotheEmbassytakenfrominformationprovidedonthisform

IhavereadandacceptedAnyVisa LtdTermsandConditions.

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