Sample DS-160 Form - US visa application form by evk20444

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									Consular Electronic Application Center - Print Application                         Page 1 of 4




Nonimmigrant Visa Application

Application - Sensitive But Unclassified(SBU)
Photo Provided:

                                                                 SAMPLE - IMMIHELP.COM


Confirmation Number:




 Personal, Address, Phone, and Passport Information
 Name Provided:                                     GUPTA , RAMESH
 Full Name in Native Language:                      DOES NOT APPLY
 ▲ Other Names Used:                                YES

      Other Name (1) :                              NONE , RAMESHBHAI
 Sex:                                               MALE
 Marital Status:                                    MARRIED
 Date of Birth:                                     01 JANUARY 1945
 Place of Birth:                                    MUMBAI , MAHARASHTRA , INDIA
 Nationality:                                       INDIA
 Other Nationalities:                               NO
 National Identification Number:                    DOES NOT APPLY
 U.S. Social Security Number:                       DOES NOT APPLY
 U.S. Taxpayer ID Number:                           DOES NOT APPLY
 Home Address:                                      34 SHANKAR LANE
 City:                                              BORIVALI
 State/Province:                                    MAHARASHTRA
 Postal Zone/ZIP Code:                              400034
 Country:                                           INDIA
 Same Mailing Address?                              YES
 Home Phone Number:                                 91-22-5555-1111
 Work Phone Number:                                 91-22-5555-1111
 Work Fax Number:                                   91-22-5555-1111
 Mobile/Cell Phone Number:                          91-22-5555-1111
 Email Address:                                     suresh@yahoo.com
 Passport Number:                                   A9783434
 Passport Book Number:                              DOES NOT APPLY
 Country/Authority that Issued Passport:            INDIA
 City Where Issued:                                 MUMBAI
 State/Province Where Issued:                       MAHARASHTRA
 Country Where Issued:                              INDIA
 Issuance Date:                                     10 JANUARY 2009
 Expiration Date:                                   28 JANUARY 2019
 Have you ever lost a passport or had one stolen?   NO
 Travel Information
Consular Electronic Application Center - Print Application                                Page 2 of 4



 Principal Applicant?                              YES
 ▲ Purpose of Your Trip to U.S.
      Purpose (1) :                                TOURIST/PERSONAL TRAVEL VISITOR (B2)
 Intended Date of Arrival:                            29 JUNE 2010
 Intended Length of Stay in U.S.:                     6 MONTH(S)
 Address where you will stay in the U.S:              123 PARK AVENUE
                                                      EDISON, NEW JERSEY 08817
 Person/Entity Paying for Your Trip:                  OTHER PERSON
 Name of Person Paying for Your Trip:                 GUPTA , RAHUL
 Telephone:                                           732-555-1212
 Email Address:                                       rahul@yahoo.com
 Relationship to You:                                 CHILD
 Is the address of the party paying for your trip the NO
 same as your Home or Mailing Address?
 Paying Address:                                      123 PARK AVENUE
 City:                                                EDISON
 State/Province:                                      NJ
 Postal Zone/ZIP Code:                                08817
 Country:                                             UNITED STATES OF AMERICA
 ▲ Other Persons Traveling with You:               YES

      Are you traveling as part of a group or      NO
      organization?
      Persons Traveling with You:
      Name (1) :                                   GUPTA , RAMILA
      Relationship to You:                         SPOUSE
 Have you ever been in the U.S.?                   NO
 Have you ever been issued a U.S. visa?            NO
 Have you ever been refused a U.S. Visa, been      NO
 refused admission to the United States, or
 withdrawn your application for admission at the
 point of entry?
 U.S. Contact Information
 Contact Person Name in the U.S.:                  GUPTA, RAHUL
 Organization Name in the U.S.:                    DO NOT KNOW
 Relationship to You:                              RELATIVE
 U.S. Contact Address:                             123 PARK AVENUE
                                                   EDISON, NEW JERSEY 08817
 Phone Number:                                     (732)555-1212
 Email Address:                                    rahul@yahoo.com
 Family Information
 Father's Surnames:                                GUPTA
 Father's Given Names:                             AMRIT
 Father's Date of Birth:                           10 JANUARY 1933
 Is your father in the U.S.?                       NO
 Mother's Surnames:                                GUPTA
 Mother's Given Names:                             SAVITA
 Mother's Date of Birth:                           10 FEBRUARY 1934
 Is your mother in the U.S.?                       NO
  ▲ Do you have any immediate relatives, not       YES

 including parents in the U.S.?
      Relative Name (1) :                          GUPTA , RAHUL
      Relationship to you:                         CHILD
      Status:                                      U.S. CITIZEN
 Spouse's   Full Name:                             GUPTA , RAMILA
 Spouse's   Date of Birth:                         29 MARCH 1947
 Spouse's   Nationality:                           INDIA
 Spouse's   City of Birth:                         DELHI
Consular Electronic Application Center - Print Application                     Page 3 of 4



 Spouse's Country of Birth:                             INDIA
 Spouse’s Address:                                      SAME AS HOME ADDRESS
 Work / Education / Training Information
 Primary Occupation:                                    BUSINESS
 Present Employer or School Name:                       STAR BAZAAR
 Address:                                               2345 KHAR LANE
 City:                                                  MUMBAI
 State/Province:                                        MAHARASHTRA
 Postal Zone/Zip Code:                                  400011
 Country:                                               INDIA
 Month Salary in Local Currency:                        45,000
 Briefly Describe your Duties:                          SALESMAN
 Security and Background Information
 Do you have a communicable disease of public           NO
 health significance such as tuberculosis (TB)?
 Do you have a mental or physical disorder that         NO
 poses or is likely to pose a threat to the safety or
 welfare of yourself or others?
 Are you or have you ever been a drug abuser or         NO
 addict?
 Have you ever been arrested or convicted for any       NO
 offense or crime, even though subject of a
 pardon, amnesty, or other similar action?
 Have you ever violated, or engaged in a                NO
 conspiracy to violate, any law relating to
 controlled substances?
 Are you coming to the United States to engage in       NO
 prostitution or unlawful commercialized vice or
 have you been engaged in prostitution or
 procuring prostitutes within the past 10 years?
 Have you ever been involved in, or do you seek to      NO
 engage in, money laundering?
 Do you seek to engage in espionage, sabotage,          NO
 export control violations, or any other illegal
 activity while in the United States?
 Do you seek to engage in terrorist activities while    NO
 in the United States or have you ever engaged in
 terrorist activities?
 Have you ever or do you intend to provide              NO
 financial assistance or other support to terrorists
 or terrorist organizations?
 Are you a member or representative of a terrorist      NO
 organization?
 Have you ever ordered, incited, committed,             NO
 assisted, or otherwise participated in genocide?
 Have you ever committed, ordered, incited,             NO
 assisted, or otherwise participated in torture?
 Have you committed, ordered, incited, assisted,        NO
 or otherwise participated in extrajudicial killings,
 political killings, or other acts of violence?
 Have you, while serving as a government official,      NO
 been responsible for or directly carried out, at any
 time, particularly severe violations of religious
 freedom?
 Have you ever sought to obtain or assist others to     NO
 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 NO
 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 NO
Consular Electronic Application Center - Print Application   Page 4 of 4



 any law or regulation?
 Have you ever renounced United States               NO
 citizenship for the purpose of avoiding taxation?
 Location Information
 Current Location:
 Preparer of Application:
 Did anyone assist you in filling out this           NO
 application?

								
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