30.
Have You Ever Been Issued a U.S. Visa? Yes No
WHERE? WHAT
TYPE OF VISA?
Select
A1 - AMBASSADOR, DIPLOMAT OR CONOFF AND IMMED FAMILY
A2 - OTHER FOREIGN GOVT OFFICIAL AND IMMEDIATE FAMILY
A3 - PERSONAL EMPLOYEE OF A1/ A2 AND IMMEDIATE FAMILY
B1 - VISITOR FOR BUSINESS
B1/B2 - VISITOR FOR BUSINESS AND PLEASURE
B2 - VISITOR FOR PLEASURE
BBBCC - B-1/ B-2/ BCC COMBINATION VISA MEX
BBBCV - B-1/B-2/BCC COMBINATION MEX LINCOLN
C1 - ALIEN IN TRANSIT
C1/D - ALIEN CREWMEMBER IN TRANSIT
C2 - ALIEN IN TRANSIT - UNITED NATIONS
C3 - TRANSIT - FOREIGN OFFICIAL/FAMILY
CP1 - SPECIAL PUBLIC BENEFIT PAROLE - PRINCIPAL APPL
CP2 - PRINCIPAL APPL SPECIAL PROGRAM FOR CUBAN MIGRATION
CP3 - SPECIAL PAROLE - FAMILY MEMBER OF CUBAN IV BENE
CP5 - SPOUSE OR CHILD OF CP-2
D - CREW MEMBER ( SHIP OR AIRCRAFT CREW)
E1 - TREATY TRADER, SPOUSE, CHILDREN
E2 - TREATY INVESTOR, SPOUSE, CHILDREN
E3 - TREATY ALIENS IN SPECIALTY OCCUPATIONS
E3D - SPOUSE AND CHILDREN OF E-3 PRINCIPALS
E3R - TREATY ALIENS IN SPECIALTY OCCUP-RETURNING E3.
F1 - STUDENT (ACADEMIC OR LANGUAGE)
F2 - SPOUSE/ CHILD OF F-1
F3 - BORDER COMMUTER STUDENT
G1 - PERM REPRESENTATIVE TO INTL ORG AND IMMED FAMILY
G2 - TEMP REPRESENTATIVE TO INTL ORG AND IMMED FAMILY
G3 - REP NONREC/MEMBER GOVT TO INTL ORG & IMMED FAMILY
G4 - EMPLOYEE OF INTL ORG AND IMMEDIATE FAMILY
G5 - PERSONAL EMPLOYEE OF G-1/2/3/4 & IMMEDIATE FAMILY
H1B - TEMP WKER DISTINGUISHED MERIT ( OTHER THAN NURSE)
H1B1 - FREE TRADE AGREEMENT NONIMMIGRANT PROFESSIONALS
H1C - SHORTAGE AREA NURSE
H2A - TEMPORARY AGRICULTURAL WORKER
H2B - NON-AGRICULTURAL TEMPORARY WORKER
H2R - RETURNING H2B WORKERS
H3 - TRAINEE
H4 - SPOUSE/ CHILD OF H1 B/1 C/2 A/2 B/3
I - FOREIGN INFO MEDIA AND SPOUSE AND CHILDREN
J1 - EXCHANGE VISITOR
J2 - SPOUSE/ CHILD OF J-1
K1 - FIANCE OR FIANCEE OF U. S. CITIZEN
K2 - CHILD OF K-1
K3 - SPOUSE OF U S CITIZEN
K4 - CHILD OF K-3
L1 - INTRA-COMPANY TRANSFEREE(EXEC, MGR)
L2 - SPOUSE/ CHILD OF L-1
M1 - VOCATIONAL/TECHNICAL STUDENT
M2 - SPOUSE/ CHILD OF M-1
M3 - BORDER COMMUTER VOCATIONAL STUDENT
N8 - PARENT OF SK3 INTL ORGANIZATION SPECIAL IMMIGRANT
N9 - CHILD OF N-8 OR OF SK1, SK2 OR SK4 SPEC IMMIGRANT
NATO1 - NATO1
NATO2 - NATO2
NATO3 - NATO3
NATO4 - NATO4
NATO5 - NATO5
NATO6 - NATO6
NATO7 - PERSONAL EMPLOYEE OF NATO-1/6
O1 - ALIEN OF EXTRAORDINARY ABILITY
O2 - ALIEN ACCOMPANYING O-1 ALIEN
O3 - SPOUSE/ CHILD OF O-1 OR O-2 ALIEN
P1 - ATHLETE OR ENTERTAINMENT GROUP - SPECIFIC EVENT
P2 - ARTIST - RECIPROCAL EXCHANGE
P3 - CULTURALLY UNIQUE ARTIST
P4 - SPOUSE/ CHILD OF P-1, P-2, OR P-3
Q1 - INTERNATIONAL CULTURAL EXCHANGE
Q2 - IRISH PEACE PROCESS TRAINEE( DUBLIN/ BELFAST ONLY)
Q3 - SPOUSE/ CHILD OF Q-2 ( DUBLIN/ BELFAST ONLY)
R1 - ALIEN IN RELIGIOUS OCCUPATION
R2 - SPOUSE/ CHILD OF R-1 ALIEN
S5 - ALIEN PROVIDING CRIMINAL INFORMATION
S6 - ALIEN PROVIDING TERRORISM INFORMATION
S7 - SPOUSE/ SON/DAUGHTER OR PARENT OF S-5 OR S-6
T2 - SPOUSE OF T1
T3 - CHILD OF T1
T4 - PARENT OF T1 CHILD
T5 - UNMARRIED SIBLING OF T1 UNDER 18
TD - N A F T A DERIVATIVE ( SPOUSE/ CHILD OF TN)
TN - N A F T A PROFESSIONAL
V1 - SPOUSE OF L P R - L I F E ACT VISA
V2 - CHILD OF L P R - CHILD PRINCIPA L - LIFE ACT
V3 - DERIVATIVE CHILD OF V1 OR V2
XX - BOARDING LTR
YY - VISAS 92
ZZ - VISAS 93
Enter Additional Visa Issuances Here:
31. Have You Ever Been
Refused a U.S. Visa? Yes No
WHERE? WHAT TYPE OF VISA?
Select
A1 - AMBASSADOR, DIPLOMAT OR CONOFF AND IMMED FAMILY
A2 - OTHER FOREIGN GOVT OFFICIAL AND IMMEDIATE FAMILY
A3 - PERSONAL EMPLOYEE OF A1/ A2 AND IMMEDIATE FAMILY
B1 - VISITOR FOR BUSINESS
B1/B2 - VISITOR FOR BUSINESS AND PLEASURE
B2 - VISITOR FOR PLEASURE
BBBCC - B-1/ B-2/ BCC COMBINATION VISA MEX
BBBCV - B-1/B-2/BCC COMBINATION MEX LINCOLN
C1 - ALIEN IN TRANSIT
C1/D - ALIEN CREWMEMBER IN TRANSIT
C2 - ALIEN IN TRANSIT - UNITED NATIONS
C3 - TRANSIT - FOREIGN OFFICIAL/FAMILY
CP1 - SPECIAL PUBLIC BENEFIT PAROLE - PRINCIPAL APPL
CP2 - PRINCIPAL APPL SPECIAL PROGRAM FOR CUBAN MIGRATION
CP3 - SPECIAL PAROLE - FAMILY MEMBER OF CUBAN IV BENE
CP5 - SPOUSE OR CHILD OF CP-2
D - CREW MEMBER ( SHIP OR AIRCRAFT CREW)
E1 - TREATY TRADER, SPOUSE, CHILDREN
E2 - TREATY INVESTOR, SPOUSE, CHILDREN
E3 - TREATY ALIENS IN SPECIALTY OCCUPATIONS
E3D - SPOUSE AND CHILDREN OF E-3 PRINCIPALS
E3R - TREATY ALIENS IN SPECIALTY OCCUP-RETURNING E3.
F1 - STUDENT (ACADEMIC OR LANGUAGE)
F2 - SPOUSE/ CHILD OF F-1
F3 - BORDER COMMUTER STUDENT
G1 - PERM REPRESENTATIVE TO INTL ORG AND IMMED FAMILY
G2 - TEMP REPRESENTATIVE TO INTL ORG AND IMMED FAMILY
G3 - REP NONREC/MEMBER GOVT TO INTL ORG & IMMED FAMILY
G4 - EMPLOYEE OF INTL ORG AND IMMEDIATE FAMILY
G5 - PERSONAL EMPLOYEE OF G-1/2/3/4 & IMMEDIATE FAMILY
H1B - TEMP WKER DISTINGUISHED MERIT ( OTHER THAN NURSE)
H1B1 - FREE TRADE AGREEMENT NONIMMIGRANT PROFESSIONALS
H1C - SHORTAGE AREA NURSE
H2A - TEMPORARY AGRICULTURAL WORKER
H2B - NON-AGRICULTURAL TEMPORARY WORKER
H2R - RETURNING H2B WORKERS
H3 - TRAINEE
H4 - SPOUSE/ CHILD OF H1 B/1 C/2 A/2 B/3
I - FOREIGN INFO MEDIA AND SPOUSE AND CHILDREN
J1 - EXCHANGE VISITOR
J2 - SPOUSE/ CHILD OF J-1
K1 - FIANCE OR FIANCEE OF U. S. CITIZEN
K2 - CHILD OF K-1
K3 - SPOUSE OF U S CITIZEN
K4 - CHILD OF K-3
L1 - INTRA-COMPANY TRANSFEREE(EXEC, MGR)
L2 - SPOUSE/ CHILD OF L-1
M1 - VOCATIONAL/TECHNICAL STUDENT
M2 - SPOUSE/ CHILD OF M-1
M3 - BORDER COMMUTER VOCATIONAL STUDENT
N8 - PARENT OF SK3 INTL ORGANIZATION SPECIAL IMMIGRANT
N9 - CHILD OF N-8 OR OF SK1, SK2 OR SK4 SPEC IMMIGRANT
NATO1 - NATO1
NATO2 - NATO2
NATO3 - NATO3
NATO4 - NATO4
NATO5 - NATO5
NATO6 - NATO6
NATO7 - PERSONAL EMPLOYEE OF NATO-1/6
O1 - ALIEN OF EXTRAORDINARY ABILITY
O2 - ALIEN ACCOMPANYING O-1 ALIEN
O3 - SPOUSE/ CHILD OF O-1 OR O-2 ALIEN
P1 - ATHLETE OR ENTERTAINMENT GROUP - SPECIFIC EVENT
P2 - ARTIST - RECIPROCAL EXCHANGE
P3 - CULTURALLY UNIQUE ARTIST
P4 - SPOUSE/ CHILD OF P-1, P-2, OR P-3
Q1 - INTERNATIONAL CULTURAL EXCHANGE
Q2 - IRISH PEACE PROCESS TRAINEE( DUBLIN/ BELFAST ONLY)
Q3 - SPOUSE/ CHILD OF Q-2 ( DUBLIN/ BELFAST ONLY)
R1 - ALIEN IN RELIGIOUS OCCUPATION
R2 - SPOUSE/ CHILD OF R-1 ALIEN
S5 - ALIEN PROVIDING CRIMINAL INFORMATION
S6 - ALIEN PROVIDING TERRORISM INFORMATION
S7 - SPOUSE/ SON/DAUGHTER OR PARENT OF S-5 OR S-6
T2 - SPOUSE OF T1
T3 - CHILD OF T1
T4 - PARENT OF T1 CHILD
T5 - UNMARRIED SIBLING OF T1 UNDER 18
TD - N A F T A DERIVATIVE ( SPOUSE/ CHILD OF TN)
TN - N A F T A PROFESSIONAL
V1 - SPOUSE OF L P R - L I F E ACT VISA
V2 - CHILD OF L P R - CHILD PRINCIPA L - LIFE ACT
V3 - DERIVATIVE CHILD OF V1 OR V2
XX - BOARDING LTR
YY - VISAS 92
ZZ - VISAS 93
Enter Additional Visa Refusals Here:
32. Do
You Intend To Work in The U.S.? Yes No(If
YES, give the name and complete address of U.S. employer.)
33. Do You Intend To Study
in The U.S.? Yes No(If YES, give the name and complete address
of the school.)
34. Names and
Relationships of Persons Traveling With You
35. Has
Your U.S. Visa Ever Been Cancelled or Revoked? Yes No
36. Has Anyone
Ever Filed an Immigrant Visa Petition on Your
Behalf? Yes No If Yes, Who?
37. Are Any of The Following
Persons in The U.S., or Do They Have U.S. Legal Permanent Residence
or U.S. Citizenship? Mark YES or NO and indicate that person's
status in the U.S. (i.e., U.S. legal permanent resident, U.S.
citizen, visiting, studying, working, etc.).
38. IMPORTANT: ALL APPLICANTS MUST READ AND
CHECK THE APPROPRIATE BOX FOR EACH ITEM. A visa may not be
issued to persons who are within specific categories defined
by law as inadmissible to the United States (except when a
waiver is obtained in advance). Is any of the following
applicable to you?
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 U.S., or
been the subject of a deportation hearing or sought to
obtain or assist others to obtain a visa, entry into the
U.S., or any other U.S. immigration benefit by fraud or
willful misrepresentation or other unlawful means? Have you
attended a U.S. 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 U.S. 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 U.S. visa, or been
unlawfully present in, or deported from, the United
States?
Yes No
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, voted in the United States in
violation of any law or regulation, or renounced U.S.
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
While a YES answer does not automatically
signify ineligibility for a visa, if you answered YES you may
be required to personally appear before a consular
officer.
39. Was
this Application Prepared by Another Person on Your
Behalf? Yes No (If answer is YES, then
have that person complete item 40.)
40.
Application Prepared By: NAME:
Relationship to Applicant: ADDRESS:
Signature of
Person Preparing
Form:____________________________________________ DATE
(dd-month-yyyy) __________________________
41. I certify that I
have read and understood all the questions set forth in this
application and the answers I have furnished on this form are true
and correct to the best of my knowledge and belief. I understand
that any false or misleading statement may result in the permanent
refusal of a visa or denial of entry into the United States. I
understand that possession of a visa does not automatically entitle
the bearer to enter the United States of America upon arrival at a
port of entry if he or she is found inadmissible. APPLICANT'S
SIGNATURE____________________________________________
DATE (dd-month-yyyy)
___________________________
Privacy and Paperwork Reduction Act
Statements
INA Section 222(f) provides that visa issuance and
refusal records shall be considered confidential and shall be used
only for the formulation, amendment, administration, or enforcement
of the immigration, nationality, and other laws of the United
States. Certified copies of visa records may be made available to a
court which certifies that the information contained in such records
is needed in a case pending before the court. Public
reporting burden for this collection of information is estimated to
average 1 hour per response, including time required for searching
existing data sources, gathering the necessary data, providing the
information required, and reviewing the final collection. You do not
have to provide the information unless this collection displays a
currently valid OMB number. Send comments on the accuracy of this
estimate of the burden and recommendations for reducing it to: U.S.
Department of State, A/RPS/DIR, Washington, DC
20520.