Nonimmigrant Visa Application
Application - Sensitive But Unclassified(SBU)
Photo Provided:
Confirmation Number:
Personal, Address, Phone, and Passport Information
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:
State/Province Where Issued:
Country Where Issued:
Issuance Date:
Expiration Date:
Have you ever lost a passport or had one stolen?
Travel Information
Principal Applicant?
Purpose of Your Trip to U.S. ▲
Purpose (1) :
YxY
文本框
自己的照片
Specific Travel Plan? ▲
Date of Arrival in U.S.:
Arrival City:
Date of Departure from U.S.:
Departure City:
The Location you plan to visit in the U.S.: ▲
Location (1):
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 trip the
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.?
Have you ever been issued a U.S. visa?
Have you ever been refused a U.S. Visa, been 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admission to the United States, or withdrawn your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.:
Organization Name in the U.S.:
Relationship to You:
U.S. Contact Address:
Phone Number:
Email Address:
Family Information
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 including
parents in the U.S.?
Do you have any other relatives in the United States?
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:
Were you previously employed?
Have you attended any educational institutions
other than elementary schools?
▲
Name of Institution (1) :
Address of Institution:
City:
State/Province:
Postal Zone/ZIP Code:
Country:
Course of Study:
Date of Attendance From:
Date of Attendance To:
Name of Institution (2) :
Address of Institution:
City:
State/Province:
Postal Zone/ZIP Code:
Country:
Course of Study:
Date of Attendance From:
Date of Attendance To:
Do you belong to a clan or tribe?
Clan or Tribe Name:
Have you traveled to any countries within the last five
years?
Have you belonged to, contributed to, or worked for
any professional, social, or charitable organization?
Do you have any specialized skills or training, including
firearms, explosives, nuclear, biological, or chemical
experience?
Have you ever served in the military?
Have you ever served in, been a member of, or been
involved with a paramilitary unit, vigilante unit, rebel
group, guerrilla group, or insurgent organization?
Security and Background Information
Do you have a communicable disease of public health
significance such as tuberculosis (TB)?
Do you have a mental or physical disorder that 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 addict? NO
Have you ever been arrested or convicted for any
offense or crime, even though subject of a pardon,
amnesty, or other similar action?
Have you ever violated, or engaged in a conspiracy to
violate, any law relating to controlled substances?
Are you coming to the United States to engage in
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
engage in, money laundering?
Do you seek to engage in espionage, sabotage, export
control violations, or any other illegal activity while in
the United States?
Do you seek to engage in terrorist activities while in the
United States or have you ever engaged in terrorist
activities?
Have you ever or do you intend to provide financial
assistance or other support to terrorists or terrorist
organizations?
Are you a member or representative of a terrorist
organization?
Have you ever ordered, incited, committed, assisted, or
otherwise participated in genocide?
Have you ever committed, ordered, incited, assisted, or
otherwise participated in torture?
Have you committed, ordered, incited, assisted, or
otherwise participated in extrajudicial killings, political
killings, or other acts of violence?
Have you, while serving as a government official, 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
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 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 any
law or regulation?
Have you ever renounced United States citizenship for
the purpose of avoiding taxation?
Student/Exchange Visa Information
Additional Point of Contact Information: ▲
Name(1):
Street Address:
City:
State/Province:
Postal Zone/ZIP Code:
Country:
Telephone Number:
Email Address:
Name(2):
Street Address:
City:
State/Province:
Postal Zone/ZIP Code:
Country:
Telephone Number:
Email Address:
SEVIS ID:
Do you intend to study in the U.S.?
Location Information
Current Location:
Preparer of Application:
Did anyone assist you in filling out this application?
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