Personal Information 1 - AnyVisa | Visa Application Services



DS-160 Visa Application Form QuestionnairePLEASE NOTE THIS IS A LEGALLY BINDING DOCUMENT. YOU MUST COMPLETE ALL FIELDS EVEN TO SAY THAT YOU DO NOT KNOW. THIS INFORMATION WILL BE SUBMITTED TO THE U.S. GOVERNMENT.Personal Information 1SurnamesGiven NamesFull Name in Native AlphabetHave 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?FemaleMarital statusChoose an item.Date of birthCity of birthState/Province of birthCountry of birthPersonal Information 2Country/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 NumberU.S. Social Security NumberU.S. Taxpayer ID NumberAddress and Phone InformationHome AddressStreet Address (Line 1)Street Address (Line 2) *OptionalCity State/ProvincePostal Zone/ZIP Code Country/Region Mailing Address?Same as Home Address aboveStreet Address (Line 1)Street Address (Line 2) *OptionalCity State/ProvincePostal Zone/ZIP Code Country/Region Primary Phone Number?Secondary Phone Number?Work Phone NumberEmail AddressPassport InformationPassport/Travel Document TypeChoose an item.Passport/Travel Document NumberPassport Book NumberPassport issue Country (citizenship)Passport issue City name (place of issue)Passport issue Country (place of issue)Issue dateExpiry dateHave you ever lost a passport or had one stolen?Passport numberPassport issue Country (citizenship)ExplainTravel InformationHave you made specific travel plans? (see below 2 options)Yes:Date of Arrival in U.S.Arrival Flight (if known)Arrival CityDate of Departure from U.S.Departure Flight (if known)Departure CityProvide the locations you plan to visit in the U.S.No:Intended Date of ArrivalIntended Length of Stay in U.S.Address Where You Will Stay in the U.S.Street Address (Line 1)Street Address (Line 2) *OptionalCity State/ProvincePostal Zone/ZIP Code Country/Region Person/Entity Paying for Your Trip? (see below 3 options)?Self?Other person:Surnames of the PersonGiven Names of the PersonTelephone NumberEmail AddressRelationship to YouChoose 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/OrganisationName of Company/Organization Paying for TripTelephone NumberRelationship to YouStreet Address (Line 1)Street Address (Line 2) *OptionalCity State/ProvincePostal Zone/ZIP Code Country/Region Travel Companions InformationAre there other persons traveling with you???No?Yes, provide the traveller’s: SurnameGiven NameRelationship to youAre you traveling as part of a group or organization??Yes – Group name:?NoPrevious U.S. Travel InformationHave you ever been in the U.S.? (see below 2 options)?No?Yes – Provide details of up to 5 previous trips1 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 IssuedVisa numberAre you applying for the same type of visa? ?Yes ?NoAre 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 ?NoHave you been ten-printed??Yes ?NoHave 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 detailsDateLocationReason for refusalHave 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 detailsDateLocationReason Have you ever been denied ESTA (electronic system for travel authority) to travel without visa? (see below 2 options)?No?Yes – Provide detailsDateLocationReason Has anyone ever filed a Green card application for permanent residence on your behalf??No?Yes: Give details:U.S. Contact InformationContact Person full name/sContact organizationRelationship to you Choose an item.Address, phone number and Email address of your contact in USStreet Address (Line 1)Street Address (Line 2) *OptionalCity State/ProvincePostal Zone/ZIP Code Phone numberEmail AddressFamily InformationFather’s Full Name (even if deceased)Father’s Date of BirthIs your father in the US??Yes ?NoMother’s Full Name (even if deceased)Mother’s Date of BirthIs your mother in the US??Yes ?NoDo 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 sheetSurnameNameRelationship to youRelative’s status? US citizen? US legal permanent resident? Non-immigrant resident? Other/do not knowDo you have any other relatives in the United States???Yes ?NoIf you are married/divorced or separated please give details of your spouseName of spouseSpouse date of birthCity/town of spouseCountry of birth of spouseSpouse’s full address, if different from applicant’s home addressIf divorced give detailsDate of marriageDate of divorceReason for divorceCountry marriage was terminatedWork/Education/Training InformationWhat is your present occupation?Name and address of employerName of employerStreet Address (Line 1)City State/ProvincePostal Zone/ZIP Code Phone numberSupervisor’s name and surnameMonthly salaryBrief Job DescriptionWere 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/AEmployer nameStreet Address City State/ProvincePostal Zone/ZIP Code CountryTelephone numberJob titleSupervisor’s full nameEmployment dates from DD/MM/YYYY to DD/MM/YYYYBrief Job DescriptionPlease provide details of the school you attended from the age of 14Name of institutionFull addressPhone numberEmail AddressAttendance datesPlease provide details of any further or higher education establishments attended NameLocationAttendance datesQualification grantedDo you belong to a clan or tribe??No?Yes: Give detailsProvide a list of languages that you speak:Please list other countries you have travelled to in the last 5 yearsHave 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 ?NoHave you ever served in the military? If yes please give details of branch, rank achieved and dates of service.?Yes ?NoSecurity and Background information If YES- provide detailsDo 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 willful misrepresentation 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 visasName of US EmployerAddress of US EmployerTelephone noMonthly SalaryPetition NoName of person/company who filed petitionHave you previously had all ten fingerprints taken by US Embassy?Appointment preferencesI prefer to submit my fingerprints on the following datesIn case the above dates are not available, I cannot go on the following datesPassport delivery preferenceI 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 questionnaire certifies that you have read and understood the questions in this application and that your answers are true to the best of your belief. The submission of an application containing false or misleading statements may result in permanent refusal of a visa or denial of entry into the United States. All declarations made in this application are unsworn declarations made under penalty of perjury, (US U.S.C. 1746)This form will be electronically submitted to the U.S. Embassy, and will be considered to have been electronically signed by you. In submitting this form to us, you are binding yourself to the US regulations above, and are accepting that an electronic signature has been made by yourself and not AnyVisa Ltd.By sending this form for processing I certify that the above information is true and complete to the best of my knowledge and understand that in signing this I am agreeing to this information being legally submitted to the United States Embassy for the purpose of making a visa application. I understand that failure to disclose information on this form may lead to my visa being refused, and future applications being rejected. AnyVisa Ltd will not be responsible for faulty information submitted to the Embassy taken from information provided on this formI have read and accepted AnyVisa Ltd Terms and Conditions. ................
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