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					U.S. Department of State

SUPPLEMENTAL NONIMMIGRANT VISA APPLICATION

Approved OMB 1405-0134 Expires 09/30/2008 Estimated Burdon 1 hour

PLEAST TYPE OR PRINT YOUR ANSWERS IN THE SPACE PROVIDED BELOW EACH ITEM PLEASE ATTACH AN ADDITIONAL SHEET IF YOU NEED MORE SPACE TO CONTINUE YOUR ANSWERS 1. Last Name(s) (List all Spellings) 2. First Name(s) (List all Spellings) 3. Full Name (in Native Alphabet) (请填中文全名) 5. 配偶全名(如已婚) 7. 母亲全名

4. Clan or Tribe Name (If Applicable) 6. Father’s Full Name 6. 父亲全名

5. Spouse’s Full Name (If Married) 7. Mother’s Full Name

8. Full Name and Address of Contact Person or Organization in the United States (Include Telephone Number)

Sherry Y.Fan President, FCC GROUP INTERNATIONAL (USA) INC. Add:9300 FLAIRDR, #305EL MONTE, CA91731 U.S.A Tel:1-626-5728966 1-625-5729858 Fax:1-626-5728967
9. List All Countries You have Entered in the Last Ten Years (Give the Year of Each Visit) 10. List All Countries That Have Ever Issued You a Passport

P.R.China
12. Not Including Current Employer, List Your Last Two Employers Name : Address : Telephone No. Supervisor’s Name: Job Title : Dates of Employment : 12. 列出上两任雇主(除现任雇主外) 公司名称: 公司地址: 电话号码: 主管姓名: Name : Address : Telephone No. Supervisor’s Name: Job Title : Dates of Employment :

11. Have You Ever Lost a Passport or Had One Stolen?
Yes No

工作职务: 起止日期:

公司名称: 公司地址: 电话号码: 主管姓名: 工作职务: 起止日期:

13. List all Professional, Social and Charitable Organizations to Which You Belong (Belonged) or Contribute (Contributed) or with Which You Work (Have Worked)…

14. Do You Have Any Specialized Skills or Training, Including Firearms, Explosives, Nuclear, Biological, or Chemical Experience? Yes No If YES, please explain

15. 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

16. Have You Ever Been in an Armed Conflict, Either as a Participant or Victim?

Yes

No

If YES, please explain.

17. List All Educational Institutions You Attend or Have Attended. Include Vocational Institutions But Not Elementary Schools. Name of Institution: Address/Telephone No. Course of Study: Name of Institution: Address/Telephone No. Course of Study Dates of Attendance : Yes No Dates of Attendance :

17. 列出所有你曾经和目前就读的学校, 包括职校, 但不包括小学。 学校名称: 地址/电话: 所学课程: 学校名称: 地址/电话: 所学课程: 起止日期: 起止日期:

18. Have You Made Specific Travel Arrangements?

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.

Schedule Attached.

Paperwork Reduction Act Statement *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. DS-157 12-2005

样表
U.S. Department of State

SUPPLEMENTAL NONIMMIGRANT VISA APPLICATION

Approved OMB 1405-0134 Expires 09/30/2008 Estimated Burdon 1 hour

PLEAST TYPE OR PRINT YOUR ANSWERS IN THE SPACE PROVIDED BELOW EACH ITEM PLEASE ATTACH AN ADDITIONAL SHEET IF YOU NEED MORE SPACE TO CONTINUE YOUR ANSWERS 1. Last Name(s) (List all Spellings) 2. First Name(s) (List all Spellings) 3. Full Name (in Native Alphabet) (请填中文全名)

Li
4. Clan or Tribe Name (If Applicable)

XXX
5. Spouse’s Full Name (If Married)

李 XX
5. 配偶全名(如已婚)

None
6. Father’s Full Name 6. 父亲全名

Xu XX
7. Mother’s Full Name

徐 XX
7. 母亲全名

Li XX

李 XXX

Huang XX

黄 XX

8. Full Name and Address of Contact Person or Organization in the United States (Include Telephone Number)

Sherry Y.Fan President, FCC GROUP INTERNATIONAL (USA) INC. Add:9300 FLAIRDR, #305EL MONTE, CA91731 U.S.A Tel:1-626-5728966 1-625-5729858 Fax:1-626-5728967
9. List All Countries You have Entered in the Last Ten Years (Give the Year of Each Visit) 10. List All Countries That Have Ever Issued You a Passport

None
12. Not Including Current Employer, List Your Last Two Employers Name : Planning and Development Bureau of Jinping County Address :No. 6, Xianrendong, Jinping, Honghe Prefecture, Yunnan Telephone No: 0873-xxxxxx Supervisor’s Name: Zhang xxx Job Title : Director General

P.R.China
12. 列出上两任雇主(除现任雇主外) 公司名称: 金平县发展计划局 公司地址: 云南省红河州金平县仙人洞 6 号 电话号码: 0873-xxxxxxx 主管姓名: 张 xx

11. Have You Ever Lost a Passport or Had One Stolen?
Yes No

Dates of Employment : 2004.4 to 2003.4

工作职务:局长 起止日期:2002.4 至 2003.4

Name: Planning Committee of Jinping County Address : No. 6, Xianrendong, Jinping, Honghe Prefecture, Yunnan Telephone No: 0873-xxxxx Supervisor’s Name: Bai xxxx Job Title : Director Dates of Employment : 1998.3-2002.4

公司名称: 金平县计划委员会 公司地址: 云南省红河州金平县仙人洞 6 号 电话号码: 0873-xxxxxx 主管姓名:白 xxx 工作职务: 主任 起止日期: 1998.3-2002.4

13. List all Professional, Social and Charitable Organizations to Which You Belong (Belonged) or Contribute (Contributed) or with Which You Work (Have Worked)…

14. Do You Have Any Specialized Skills or Training, Including Firearms, Explosives, Nuclear, Biological, or Chemical Experience? Yes No If YES, please explain

None
15. 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

16. Have You Ever Been in an Armed Conflict, Either as a Participant or Victim?

Yes

No

If YES, please explain.

17. List All Educational Institutions You Attend or Have Attended. Include Vocational Institutions But Not Elementary Schools. Name of Institution: Yunnan Nationalities College Course of Study: Economy Management Name of Institution: Address/Telephone No. Course of Study Dates of Attendance : Yes No 0871-5156789 Address/Telephone No: No.134, Yi’eryi Street, Kunming, Yunnan, P.R.China Dates of Attendance : 1986.9-1998.7

17. 列出所有你曾经和目前就读的学校, 包括职校, 但不包括小学。 学校名称: 云南民族学院 地址/电话: 昆明市一二一大街 134 号 电话:0871-5156789 所学课程: 经济管理 学校名称: 地址/电话: 所学课程: 起止日期: 起止日期: 1986.9-1998.7

18. Have You Made Specific Travel Arrangements?

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.

Schedule Attached.

Paperwork Reduction Act Statement *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. DS-157 12-2005


				
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