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Nonimmigrant Visa Application
Application - | Sensitive But Unclassified(SBU) |
Photo Provided: | ||||
Confirmation Number确认号: | ||||
Personal, Address, Phone, and PassportInformation | ||||
Name Provided: | ||||
Full Name in Native Language: | ||||
Other Names Used: | ||||
Sex: | ||||
Marital Status: | ||||
Date of Birth: | ||||
Place of Birth: | ||||
Nationality: | ||||
Other Nationalities: | ||||
National Identification Number: | ||||
U.S. Social Security Number: | ||||
U.S. Taxpayer ID Number: | ||||
Home Address: | |
City: | |
State/Province: | |
Postal Zone/ZIP Code: | |
Country: | |
Same Mailing Address? | |
Mailing Address: | |
City: | |
State/Province: | |
Postal Zone/ZIP Code: | |
Country: | |
Home Phone Number: | |
Work Phone Number: | |
Work Fax Number: | |
Mobile/Cell Phone Number: | |
Email Address: |
Passport Number: | |
Passport Book Number: | |
Country/Authority that Issued Passport: | |
City Where Issued: | |
Country Where Issued: | |
Issuance Date: | |
Expiration Date: | |
Have you ever lost a passport or had onestolen? |
TravelInformation | |||||||
Principal Applicant? | |||||||
▲ Purpose of Your Trip toU.S. | |||||||
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Intended Date of Arrival: | |||||||
Intended Length of Stay in U.S.: | |||||||
Address where you will stay in the U.S: | |||||||
Person/Entity Paying for Your Trip: | |||||||
Name of Company/Organization Paying for Trip: | |||||||
Telephone: | |||||||
Relationship to You: | |||||||
Is the address of the party paying for your tripthe same as your Home or Mailing Address? | |||||||
Paying Address: | |||||||
City: | |||||||
State/Province: | |||||||
Postal Zone/ZIP Code: | |||||||
Country: |
Other Persons Traveling with You: |
▲ Have you ever been in the U.S.? | |||||||||||||
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Do you or did you hold a U.S. Driver's License? | |||||||||||||
Have you ever been issued a U.S. visa? | |||||||||||||
Have you ever been refused a U.S. Visa, beenrefused admission to the United States, or withdrawn yourapplication for admission at the point of entry? |
U.S. ContactInformation | |
Contact Person Name in the U.S.: | |
Organization Name in the U.S.: | |
Relationship to You: | |
U.S. Contact Address: | |
Phone Number: | |
Email Address: |
FamilyInformation | |
Father's Surnames: | |
Father's Given Names: | |
Father's Date of Birth: | |
Is your father in the U.S.? | |
Mother's Surnames: | |
Mother's Given Names: | |
Mother's Date of Birth: | |
Is your mother in the U.S.? | |
Do you have any immediate relatives, not includingparents in the U.S.? | |
Do you have any other relatives in the UnitedStates? |
Spouse's Full Name: | |
Spouse's Date of Birth: | |
Spouse's Nationality: | |
Spouse's City of Birth: | |
Spouse's Country of Birth: | |
Spouse’s Address: |
Work / Education / Training Information | |
Primary Occupation: | |
Present Employer or School Name: | |
Address: | |
City: | |
State/Province: | |
Postal Zone/Zip Code: | |
Country: | |
Month Salary in Local Currency: | |
Briefly Describe your Duties: |
Security and Background Information安全与背景:医疗与健康信息 | |
Do you have a communicable disease of public healthsignificance such as tuberculosis (TB)? | NO |
Do you have a mental or physical disorder thatposes or is likely to pose a threat to the safety or welfare ofyourself or others? | NO |
Are you or have you ever been a drug abuser oraddict? | NO |
Have you ever been arrested or convicted for anyoffense or crime, even though subject of a pardon, amnesty, orother similar action? | NO |
Have you ever violated, or engaged in a conspiracyto violate, any law relating to controlled substances? | NO |
Are you coming to the United States to engage inprostitution or unlawful commercialized vice or have you beenengaged in prostitution or procuring prostitutes within the past 10years? | NO |
Have you ever been involved in, or do you seek toengage in, money laundering? | NO |
Do you seek to engage in espionage, sabotage,export control violations, or any other illegal activity while inthe United States? | NO |
Do you seek to engage in terrorist activities whilein the United States or have you ever engaged in terroristactivities? | NO |
Have you ever or do you intend to provide financialassistance or other support to terrorists or terroristorganizations? | NO |
Are you a member or representative of a terroristorganization? | NO |
Have you ever ordered, incited, committed,assisted, or otherwise participated in genocide? | NO |
Have you ever committed, ordered, incited,assisted, or otherwise participated in torture? | NO |
Have you committed, ordered, incited, assisted, orotherwise participated in extrajudicial killings, politicalkillings, or other acts of violence? | NO |
Have you, while serving as a government official,been responsible for or directly carried out, at any time,particularly severe violations of religious freedom? | NO |
Have you ever been the subject of a removal ordeportation hearing? | NO |
Have you ever sought to obtain or assist others toobtain a visa, entry into the United States, or any other UnitedStates immigration benefit by fraud or willful misrepresentation orother unlawful means? | NO |
Have you failed to attend a hearing on removabilityor inadmissibility within the last five years? | NO |
Have you ever been unlawfully present, overstayedthe amount of time granted by an immigration official or otherwiseviolated the terms of a U.S. visa? | NO |
Have you ever withheld custody of a U.S. citizenchild outside the United States from a person granted legal custodyby a U.S. court? | NO |
Have you voted in the United States in violation ofany law or regulation? | NO |
Have you ever renounced United States citizenshipfor the purpose of avoiding taxation? | NO |
Have you attended a public elementary school onstudent (F) status or a public secondary school after November 30,1996 without reimbursing the school? | NO |
LocationInformation递交申请的地点 | |
Current Location: | |
Preparer of Application: |
Did anyone assist you in filling out thisapplication? | 是否有人帮助您填写申请表? |
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