???? ???? ?????? ???? ????? ???? ? ds 160 ???? ?? ???? ???? ???? ?? ??????? ??? ? by ULJo77p

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									                     DS-160 ‫טופס בקשה להנפקת אשרת כניסה לארה"ב‬
            .‫* טופס זה אינו טופס רשמי של שגרירות ארה"ב, ונועד להקל עליך בתהליך הגשת הבקשה‬
                                                               .‫* טופס זה הינו חובה לכל מבקש, בכל גיל‬
                                                                                      ‫* נא למלא באנגלית‬
                                                                                           :‫1. פרטים אישיים‬
1.1. Last name:                                           1.2. Given Names:
1.3. Other names used:
1.4. ‫שם מלא בעברית‬                                        1.5. Sex:

1.6. Marital Status:                                      1.7. Date of Birth:

1.8. City Of Birth:                                       1.9. Country Of Birth:

1.10. Nationality:                                        1.11. National ID No.:



                                                                                        :‫2. לבעלי אזרחות זרה‬
2.1. Other Nationalities        1.                        2.                          3.
2.2. Passport No.               1.                        2.                          3.
2.3. U.S. Social Security No:
2.4. U.S. tax payer ID:



                                                                                   :‫3. כתובת ופרטי התקשרות‬
3.1. Home Address:
3.2. City                                                  3.3. ZIP Code:
3.4. Other mail address:
3.5. Home Phone No.:                                       3.6. Work Phone No.:
3.7. E-mail Address:                                       3.8. Mobile Phone No.:



                                                                                               :‫4. פרטי דרכון‬
4.1. Passport No.:                                   4.2. Country/Authority that
                                                     Issued Passport:
4.3. City Where Issued:                              4.4. Country Where Issued:
4.5. Issue Date:                                     4.6. Expiry Date:
4.7. Has your passport ever been lost or stolen? If yes- please specify yea & country




                                        Amsalem Tours and Travel Ltd.
               3 Haprahim St., Tiberias 14100, Israel, Tel: +972-4-6700900, Fax: +972-4-6723491
                                     info@amsalem.com, www.amsalem.com
                                                                                           :‫5. פרטי הנסיעה‬
5.1. Purpose of Your Travel:
5.2. Intended Date of Arrival:                         5.3. Intended Length of Stay:
5.4. Person/Entity Paying for Your Trip: Full name &
Address
5.5. Other Persons Traveling with You: Full name &
Relation to you


                                                                              :‫6. ביקורים קודמים בארה"ב‬
6.1. Have you ever been in the U.S.?
Previous U.S. Visits in the Last 5 Years:
Travel Date of Arrival:                                Length of Stay:
Travel Date of Arrival:                                Length of Stay:
Travel Date of Arrival:                                Length of Stay:
Travel Date of Arrival:                                Length of Stay:
Travel Date of Arrival:                                Length of Stay:
6.2. Do you or did you hold a U.S. Driver's License?
6.3 License no. & State where issued:


                                                                                            :‫7. ויזה קודמת‬
7.1. Have you ever been                        7.2. Last Visa Issue Date:
issued a U.S. Visa?
                                               7.3. Visa No.
7.4. Have you ever been refused a U.S. Visa, been refused admission to the United
States, or withdrawn your application for admission at the point of entry?
7.5. ?‫האם אי פעם נתת טביעת 10 אצבעות‬
7.6. Has your U.S. Visa ever been lost or stolen? Please state year
7.7. Has your U.S. Visa ever been cancelled or revoked?



                                                                                             :‫8. אנשי קשר‬
8.1. Contact Person OR
Organization Name in the U.S.:
8.2. U.S. Contact Full Address:

8.3. Phone No.:                                                8.4. Relationship to You:




                                       Amsalem Tours and Travel Ltd.
              3 Haprahim St., Tiberias 14100, Israel, Tel: +972-4-6700900, Fax: +972-4-6723491
                                     info@amsalem.com, www.amsalem.com
                                                                                            :‫9. מידע משפחתי‬
9.1. Father's Last name:                                 9.2. Father's Given Names:
9.3. Mother's Last name:                                 9.4. Mother's Given Names:
9.5. Father's Date of Birth:                             9.6. Mother's Date of Birth:
9.7. Is your father in the                               9.8. Is your mother in the U.S.?
U.S.?
9.9. Do you have any immediate relatives, not including parents in the U.S.?
9.10. Full Name
9.11. Relationship to You                                9.12. Relative's Status
9.13. Do you have any other relatives in the United States?



                                                                                              :‫11. פרטי בן זוג‬
10.1. Spouse's Full Name:
10.2. Spouse's Date of Birth:                               10.3. Spouse's City of Birth:
10.4. Spouse's Country of Birth:                            10.5. Spouse's Nationality:
10.6. Spouse’s Address:



   :‫11. פרטי עבודה/לימודים: פנסיונרים/עקרות-בית/לא-מועסקים- נא למלא את פרטי המעסיק האחרון‬
11.1. Present Employer or School:
11.2. Full Address:
11.3. Monthly Salary in ILS (if employed):
11.4. Briefly Describe Your Duties:



                                                                                            :‫21. שאלון בריאות‬
12.1. Do you have a communicable disease of public health significance such as
tuberculosis (TB)?
12.2. Do you have a mental or physical disorder that poses or is likely to pose a
threat to the safety or welfare of yourself or others?
12.3. Are you or have you ever been a drug abuser or addict?




                                        Amsalem Tours and Travel Ltd.
               3 Haprahim St., Tiberias 14100, Israel, Tel: +972-4-6700900, Fax: +972-4-6723491
                                      info@amsalem.com, www.amsalem.com
                                                                                                   :‫11. שאלון פשיעה‬
13.1. Have you ever participated, or intend to participate in any illegal, criminal, or
otherwise unlawful activity; including prostitution (or procuring prostitutes), conspiracies
of violation of laws relating to controlled substances, money laundering, espionage,
sabotage or terrorist activities?
13.2. Have you ever been arrested or convicted for any offense or crime, even though
subject of a pardon, amnesty, or other similar action?
13.3. Have you ever been or are you a member or representative of a terrorist
organization, or do you intend to provide financial assistance or other support to
terrorists or terrorist organizations?
13.4. Have you ever ordered, incited, committed, assisted, or otherwise participated in
genocide, torture, extrajudicial killings, political killings, or severe violations of religious
freedom?



                                                                                                   :‫41. שאלון הגירה‬
14.1. Have you ever been the subject of a removal or deportation hearing, or have you
ever failed to attend a deportation, removability or inadmissibility hearing?
14.2. Have you ever 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?
14.3. 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?



                                                                                                   :‫51. שאלות שונות‬
0..0. Have you ever withheld custody of a U.S. citizen child outside the U.S. from a
person granted legal custody by a U.S. court?
15.2. Have you voted in the United States in violation of any law or regulation?
15.3. Have you ever renounced U.S. citizenship for the purpose of avoiding taxation?
15.4. Have you attended a public elementary school on student (F) status or a public
secondary school after November 30, 1996 without reimbursing the school?




                                        Amsalem Tours and Travel Ltd.
               3 Haprahim St., Tiberias 14100, Israel, Tel: +972-4-6700900, Fax: +972-4-6723491
                                        info@amsalem.com, www.amsalem.com
                                                     16-46 ‫ נספח לגברים בגילאי‬DS-157 .16

                                                                                                 :‫שרות צבאי‬
0..0. Have you ever served in the military?                             16.2. Country:
16.3. Branch of Service:                                                16.4. Rank/Position:
16.5. Military Specialty:
16.6. Dates of Service:            From                                 To

                                                                                                :‫מעסיק קודם‬
16.7. Were you previously employed?                          16.8.Employer name:
16.9. Full Address:
16.10. Telephone No.:                                        16.11. Job Title:
16.12. Supervisor's Full Name:                               16.13. Briefly describe
                                                             your duties:
16.14. Employment Date:            From                                  To

                                                                                               :‫מוסדות לימוד‬
16.15. Have you attended any educational institutions other than elementary schools?
16.16. Name of Institution:
16.17. Full address:
16.18. Course of study:
16.19. Date of Attendance:         From                                  To

                                                                                 :‫מוסד לימוד נוסף – אם יש‬
16.20. Name of Institution:
16.21. Full address:
16.22. Course of study:
16.23. Date of Attendance:         From                                  To

                                                                                               :‫שאלות שונות‬
16.24. 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?
16.25. Have you belonged to, contributed to, or worked for any professional, social, or
charitable organization?
16.26. Do you have any specialized skills or training, such as firearms, explosives, nuclear,
biological, or chemical experience?
16.27. Have you traveled to any countries within the last five years?
If yes – to which countries?




                                       Amsalem Tours and Travel Ltd.
              3 Haprahim St., Tiberias 14100, Israel, Tel: +972-4-6700900, Fax: +972-4-6723491
                                     info@amsalem.com, www.amsalem.com
                                                                                                      ‫תכנית נסיעה:‬
‫?‪16.28. Have you made specific travel plans‬‬
‫:.‪If yes, Provide a complete itinerary for your travel to the U.S‬‬
‫.‪Date of Arrival in U.S‬‬                                             ‫‪Arrival City‬‬
‫.‪Date of Departure from U.S‬‬                                         ‫‪Departure City‬‬
‫:.‪16.29 Provide the locations you plan to visit in the U.S‬‬




                                                                                                       ‫הערות נוספות‬




                                                                                                      ‫לקוח יקר,‬
     ‫* טופס זה אינו טופס רשמי של שגרירות ארה"ב, כי אם גרסה מודפסת של הטופס המקוון שנמצא באתר‬
                                 ‫השגרירות. טופס זה נועד להקל עליך בתהליך הגשת הבקשה לאשרה.‬
                                                                      ‫* טופס זה הינו חובה לכל מבקש, בכל גיל.‬
                                                                                   ‫* יש למלא את הטופס באנגלית.‬
                                                                                     ‫* כל השדות הם שדות חובה.‬
                           ‫* תאריכים יש לרשום בפורמט מלא (‪ ,)D/M/YY‬למעט סעיפים במציינים שנה בלבד.‬
                                                          ‫* את הטופס המלא (ממולא) יש לשלוח אלינו בצירוף:‬
                                               ‫0. צילום\סריקה של הדרכון (העמוד עם התמונה והפרטים)‬
                                                 ‫2. תמונת פספורט בצבע, גודל .*. ס"מ (בפורמט ‪)JPG‬‬
                                                  ‫3. במידה ויש- הארכת דרכון, ויזה קודמת ו/או שינוי שם‬
                                                                       ‫באי-מייל: ‪Visa-Dept@amsalem.com‬‬
                                                 ‫(*תמונות יש להעביר בדואר או במייל בלבד)‬   ‫או בפקס: 660116.-01‬


                 ‫לשאלות ובירורים ניתן לפנות במייל (‪ )Visa-Dept@amsalem.com‬או בטלפון 000-666-1100.‬


                                   ‫תודה,‬
                ‫מחלקת ויזות ודרכונים.‬
            ‫אמסלם תיירות ונופש בע"מ‬


                                       ‫.‪Amsalem Tours and Travel Ltd‬‬
              ‫1943276-4-279+ :‪3 Haprahim St., Tiberias 14100, Israel, Tel: +972-4-6700900, Fax‬‬
                                      ‫‪info@amsalem.com, www.amsalem.com‬‬

								
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