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: email@example.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: firstname.lastname@example.org 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 NO Have you ever been refused a U.S. Visa, been NO refused admission to the United States, or withdrawn your application for admission at the point of entry?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: email@example.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?
Pages to are hidden for
"Sample DS-160 Form - US visa application form"Please download to view full document