U.S.A Visa Application Form

Surname (Family Name):

Given Name (First Name):

Full Name in Native Alphabet:

Sex:

Marital Status:

Date of Birth:

Have you used other names? (Alias, Maiden etc.)

Yes No

Other Surname:

Other Given Name:

Do you have a telecode that represents your name?

Yes No

Telecode Surname:

Telecode Given Name:

Primary Nationality:

National Identification Number:

U.S. Social Security Number (if any):

U.S. Taxpayer ID Number (if any):

Do you hold or have you held any nationality other than the one indicated above?

Yes No

Other Country Nationality:

Do you hold a passport for this other country?

Yes No

Passport Number:

Are you a permanent resident of a country/region other than your principal country of nationality?

Yes No

Other Permanent Resident Country/Region Name:

Street Address:

City:

State / Province:

Postal Code / ZIP:

Country:

Is your Mailing Address the same as your Home Address?

Yes No

Passport/Travel Document Type:

Passport/Travel Document Number:

Passport Book Number (if any):

Country of Issuance:

City of Issuance:

State of Issuance:

Issuance Date:

Expiration Date:

Have you ever lost your passport or had one stolen?

Yes No

Lost Passport Number:

Country:

Explain Reason:

Purpose of Trip to U.S.:

Have you made specific travel plans?

Yes No

Date of Arrival in U.S:

Arrival Flight (If known):

Arrival City:

Date of Departure:

Departure Flight (If known):

Departure City:

Provide the locations you plan to visit in U.S:

Street Address:

City:

State:

ZIP Code:

Intended Length of Stay in U.S.:

Person/Entity Paying for Trip:

Surname / Company Name:

Given Name:

Telephone Number:

Email:

Address:

Relationship to You:

Are there any other persons traveling with you?

Yes No

Are you traveling as part of a group or organization?

Yes No

Group Name:

Have you ever been in the U.S.?

Yes No

Date of Arrival:

Length of Stay:

Do you or have you ever held a U.S. Driver's License?

Yes No

Driver's License Number:

State of Driver's License:

Have you ever been issued a U.S. visa?

Yes No

Date Last Visa Issued:

Visa Number (If any):

Are you applying for the same type of visa?

Are you applying in the same country/location of residency?

Have you ever been Ten-Printed (Fingerprinted)?

Has your U.S. visa ever been lost, stolen or cancelled?

Year Stolen/Cancelled:

Explanation:

Have you ever been refused a U.S. Visa, admission, or withdrawn application at port of entry?

Yes No

Explain Refusal Reason:

Has anyone ever filed an immigration petition on your behalf with USCIS?

Yes No

Explain Petition Details:

Contact Person Surname:

Given Name:

Organization Name (if applicable):

Relationship to You:

Email Address:

U.S. Street Address:

City:

State:

ZIP Code:

Phone Number:

Father's Surname:

Given Name:

Date of Birth:

Is your Father in the U.S.?

Father's U.S. Status:

Mother's Surname:

Given Name:

Date of Birth:

Is your Mother in the U.S.?

Mother's U.S. Status:

Spouse Surname:

Given Name:

Date of Birth:

Is your Spouse in the U.S.?

Spouse U.S. Status:

Do you have any immediate relatives (not including parents) in the United States?

Yes No

Relative Surname:

Given Name:

Relationship to You:

Relative Status (Citizen/LPR/Visa):

Primary Occupation:

Employer Name:

Street Address:

City:

State/Province:

ZIP Code/Postal Code:

Phone Number:

Country:

Start Date:

Monthly Income (Local Currency):

Briefly Describe Your Duties:

10. Previous Work Information

Were you previously employed?

Yes No

11. Education Information

Have you attended any educational institutions at a secondary level or above?

Yes No

Do you belong to a clan or tribe?

Clan Name:

Language:

Have you ever served in the military?

Country:

Branch:

Rank:

Specialty:

Have you traveled to any countries/regions within the last 5 years?

List any professional, social, or charitable organizations you have worked for or contributed to:

Do you have any specialized skills or training? (e.g., chemical, nuclear, biological, firearms experiences)

Have you ever been involved with a paramilitary unit, vigilante unit, rebel group, guerrilla group, or insurgent organization?

Explain Involvement Details:

Social Media Presence:

Provide your social media identifiers (e.g., Facebook, Instagram, LinkedIn, etc.)

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