Visa Application Questionnaire

Passport Number

Issuing Country

Place of Issuance (City/State)

Place of Issuance (Country)

Issuance Date (mm/dd/yyyy)

Expiration Date (mm/dd/yyyy)

Family Name

First Name

Middle Name

Father’s Name (First/Middle/Last)

Mother’s Name (First/Middle/Last)

All Other Names Used Including Maiden Name

E-mail Address

Address (Street Number and Name)

Suite/Apt Number

City

State

Country

Zip Code

Home Phone Number

Business Phone Number

Cell Phone Number

Home Fax Number

Business Fax Number

Page Number

Date of Birth (mm/dd/yyyy)

City of Birth

State of Birth

Country of Birth

Country of Citizenship

National Identification Number

Sex

Male Female

Marital Status

Single Married Divorced Widowed

Name of Spouse or Ex-Spouse (First/Middle/Last)

Spouse’s Date of Birth (mm/dd/yyyy)

Spouse Address (Street Number and Name)

Suite/Apt Number

City

State

Country

Zip Code

Current Employer Name

Address

Phone Number

City

State

Country

Zip Code

Occupation

Supervisor Name

From (mm/dd/yyyy)

To (mm/dd/yyyy)

Previous Employer Name

Address

Phone Number

City

State

Country

Zip Code

Occupation

Supervisor Name

From (mm/dd/yyyy)

To (mm/dd/yyyy)

Previous Employer Name

Address

Phone Number

City

State

Country

Zip Code

Occupation

Supervisor Name

From (mm/dd/yyyy)

To (mm/dd/yyyy)

Previous Employer Name

Address

Phone Number

City

State

Country

Zip Code

Occupation

Supervisor Name

From (mm/dd/yyyy)

To (mm/dd/yyyy)

Address where you will reside in the US

Suite/Apt Number

City

State

Zip Code

Name of person you are visiting in the US

Phone Number

Business Number

Cell Number

Date you intend to arrive in the US (mm/dd/yyyy)

How long do you intend to stay in the US?

What is the purpose of your trip?

Who will pay for your trip?

List all countries that have issued you a passport.

Have you ever lost a passport or had one stolen?

Yes No

List all Countries you have entered in the past 10 years and give the year for each visit

Have you ever been to the US before

Yes No

If yes, provide all previous entry dates (mm/dd/yyyy) and the duration of each visit

Do you intend to work in the US?

Yes No

If yes, give the name and complete address of US employer.

Do you intend to study in the US?

Yes No

If yes, give the name and complete address of the school.

Have you ever been issued a US visa?

Yes No

When? (mm/dd/yyyy)

Where? (City/State/Country)

What type of visa?

Enter additional visa issuance information here.

Have you ever been refused a US visa?

Yes No

When? (mm/dd/yyyy)

Where? (City/State/Country)

What type of visa?

Enter additional visa refusal information here.

Has your US visa ever been canceled or revoked?

Yes No

Has anyone filed an immigrant petition on your behalf?

Yes No

Have you ever been arrested or convicted for any offense or crime, even though subject of a pardon, amnesty or other similar legal action? Have you ever unlawfully distributed or sold a controlled substance(drug), or been a prostitute or procurer for prostitutes?

Yes No

Have you ever been refused admission to the US, or been the subject of a deportation hearing or sought to obtain or assist others to obtain a visa, entry into the US, or any other US immigration benefit by fraud or willful misrepresentation or other unlawful means? Have you attended a US public elementary school on student (F) status or a public secondary school after November 30, 1996 without reimbursing the school?

Yes No

Do you seek to enter the United States to engage in export control violations, subversive or terrorist activities, or any other unlawful purpose? Are you a member or representative of a terrorist organization as currently designated by the US Secretary of State? Have you ever participated in persecutions directed by the Nazi government of Germany; or have you ever participated in genocide?

Yes No

Have you ever violated the terms of a US visa, or been unlawfully present in, or deported from, the United States?

Yes No

Have you ever withheld custody of a US citizen child outside the United States from a person granted legal custody by a US court, voted in the United States in violation of any law or regulation, or renounced US citizenship for the purpose of avoiding taxation?

Yes No

Have you ever been afflicted with a communicable disease of public health significance or a dangerous physical or mental disorder, or ever been a drug abuser or addict?

Yes No

Name (First/Middle/Last)

Relationship

Address

Phone Number

US Status

None US Citizen LPR Visa holder

None US Citizen LPR Visa holder

None US Citizen LPR Visa holder

None US Citizen LPR Visa holder

None US Citizen LPR Visa holder

Name (First/Middle/Last)

Phone Number

Address

Name (First/Middle/Last)

Phone Number

Address

List all Professional, Social and Charitable Organizations to which currently or previously belong, contribute or work.

Do you have any specialized skills or training, including firearms, explosives, nuclear, biological, or chemical experience?

Yes No

Have you ever performed military service?

Yes No

If yes, give name of country, branch of service, rank/position, military specialty, and dates of service.

Have you ever been in an armed conflict, either as a participant or victim?

Yes No

If yes, please explain.

Have you made specific travel arrangements?

Yes No

If yes, please provide a complete itinerary for your travel, including arrival/departure dates, flight information, specific location you will visit, and a point of contact at each location.

List all educational institutions you attend or have attended. Include vocational institutions but not elementary schools.

Name

Address/Phone

Course of Study

Attendance (mm/dd/yyyy)

Name

E-mail Address