USA Visa Application

Personal

Full name*Full Name in Native AlphabetHave you ever used other names?*Other Surnames UsedDo you've telecode represents your name?*
TelecodeSex*Date of Birth*City of Birth*State/Province of Birth*Country/Region of Birth*
Nationality*
Do you have other nationality?*
Do you hold a passport other country?*
Other Country/Region of Originyou permanent resident of country?*Other Permanent Resident CountryNational Identification NumberU.S. Social Security NumberU.S. Taxpayer ID Number

Trip Information

Purpose of Trip to the U.S.*Specify*Person/Entity Paying for Your Trip*Have you made specific travel plans?*Intended / Date of Arrival in U.S.*Intended / Date of Departure from U.S.*Arrival Flight
Arrival CityDeparture FlightDeparture CityIntended Length of Stay in U.S.*
Full Address Where You Will Stay in the U.S.*

Travel Companion

Are other persons traveling with you?*
Are you traveling as part of group/organization?*
Group Name
How many persons are traveling with you
Full name of the person traveling with you
Relationship with PersonFull name of the person traveling with youRelationship with PersonFull name of the person traveling with you
Relationship with PersonFull name of the person traveling with youRelationship with PersonFull name of the person traveling with you
Relationship with PersonFull name of the person traveling with youRelationship with Person

Previous Travel

Have you ever been in the U.S.?*
Provide information on your last five U.S. visits:Do you or did you ever hold a U.S. Driver’s License?*Have you ever been refused a U.S. Visa, or been refused admission to the United States, or withdrawn your application for admission at the port of entry? *If your answer is yes, explain
Has anyone ever filed an immigrant petition on your behalf with the United States Citizenship and Immigration Services?*

Previous Travel II

If your answer is yes, explainHave you ever been issued a U.S. Visa?*
Date Last Visa Was Issued (Skip if does not apply)Visa Number (Skip if does not apply)Are you applying in the same country or location where the visa above was issued, and is this country or location your place of principal of residence? (Skip if does not apply)
Are you applying for the same type of visa? (Skip if does not apply)
Have you been ten-printed? (Skip if does not apply)
Has your U.S. Visa ever been lost or stolen? (Skip if does not apply)
Has your U.S. Visa ever been cancelled or revoked? (Skip if does not apply)
If your answer is yes, explain

Contact Information

Home Address*
City*State/Province*Postal Zone/ZIP Code*Country/Region*Is your Mailing Address the same as your Home Address?*Mailing AddressPhone Number*
Type*
Have you used any other phone numbers in the last five years?*
Additional Phone NumberEmail Address*Additional email addresDo you wish to provide information about your presence on any other websites or applications you have used within the last five years to create or share content (photos, videos, status updates, etc.)?*
Do you have a social media presence?*
Social Media Provider/PlatformSocial Media Identifier

Passport

Passport/Travel Document Type*
Passport/Travel Document Number*Passport Book NumberCountry/Authority that Issued Passport/Travel Document*Country where was the Passport/Travel Document Issued?*City*State/Province*Issuance Date*Expiration Date*
Have you ever lost a passport or had one stolen?*
Enter the name of the store, company, or organization you plan to visit during your trip
Relationship to You (Skip if dos not apply)
U.S. Street Address
City
State
ZIP Code
Phone Number
Email

Family Information

Father's Full Name*Date of Birth*
Is your father in the U.S.?*
Father's Status(Skip if not apply)
Mother's Full Name*Date of Birth*
Is your Mother in the U.S.?*
mother status(Skip if not apply)
Do you have other relatives in the U.S?*
Full NameRelationship to YouRelative's StatusMarital Status*
Spouse address
If you select other, specify
Spouse's Full NameDate of BirthSpouse's Place of Birth

Job / Education

Primary Occupation*
Present Employer or School Name*Present employer or school address:*Start Date*
Monthly Income in Local Currency (Skip if does not apply)Briefly describe your duties:
Were you previously employed?*
Job TitleSupervisor's full nameEmployment Date FromEmployment Date To

Job / Education II

Previous Employment Briefly describe your duties:
Have you attended any educational institutions at a secondary level or above?*
Name of InstitutionFull AddressCourse of StudyDate of Attendance FromDate of Attendance To

Security Questions

Do you belong to a clan or tribe?*
Clan or Tribe NameProvide a List of Languages You Speak*Have you traveled to any countries/regions within the last five years?*Country/RegionHave you belonged to, contributed to, or worked for any professional, social, or charitable organization?*
Organization NameDo you have any specialized skills or training, such as firearms, explosives, nuclear, biological, or chemical experience?*
If your answer is yes, explain

Security Questions II

Have you ever served in the military?*
Branch of Military ServiceRank/PositionMilitary SpecialtyDate of Service FromDate of Service ToHave you ever served in, been a member of, or been involved with a paramilitary unit, vigilante unit, rebel group, guerrilla group, or insurgent organization?*
If your answer is yes, explainDo 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?*
If your answer is yes, explain

Security Questions III

Are you or have you ever been a drug abuser or addict?*
If your answer is yes, explainHave you ever been arrested or convicted for any offense or crime, even though subject of a pardon, amnesty, or other similar action?*
If your answer is yes, explainHave you ever violated, or engaged in a conspiracy to violate, any law relating to controlled substances?*
If your answer is yes, explainAre 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?*
If your answer is yes, explain

Security Questions IV

Have you ever been involved in, or do you seek to engage in, money laundering?*
If your answer is yes, explainHave you ever committed or conspired to commit a human trafficking offense in the United States or outside the United States?*
If your answer is yes, explainHave you ever knowingly aided, abetted, assisted or colluded with an individual who has committed, or conspired to commit a severe human trafficking offense in the United States or outside the United States?*
If your answer is yes, explainAre you the spouse, son, or daughter of an individual who has committed or conspired to commit a human trafficking offense in the United States or outside the United States and have you within the last five years, knowingly benefited from the trafficking activities?*
If your answer is yes, explain

Security Questions V

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 purposes of avoiding taxation?*
Do you seek to engage in espionage, sabotage, export control violations, or any other illegal activities 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 terrorist or terrorist organizations?*
Are you a member or representative of a terrorist organization?*
Are you the spouse, son, or daughter of an individual who has engaged in terrorist activities, including providing financial assistance or other support to terrorists or terrorist organizations, in the last five years?*
Have you ever ordered, incited, committed, assisted or otherwise participated in genocide?*
Have you ever committed, ordered, incited, assisted or otherwise participated in torture?*

Security Questions VI

Have you committed, ordered, incited, assisted, or otherwise participated in extrajudicial killings, political killings, or other acts of violence?*
Have you ever engaged in the recruitment or the use of child soldiers?*
Have you, while serving as a governmet official, been responsible for or directly carried out, at any time, particularly severe violations of religious freedom?*
Have you ever been directly involved in the establishment or enforcement of population controls forcing a woman to undergo an abortion against her free choice or a man or a woman to undergo sterilization against his or her free will?*
Have you ever been directly involved in the coercive transplantation of human orgasm or bodily tissue?*
If any of your answers is yes, explain yourself

Consent

I declare that I have answered all the questions in this application completely and truthfully
I certify that the information contained in this document is complete, accurate and objective. I also realize that once this document has been completed and signed, it will become part of my immigration record and will be used to verify my family details in future applications
I agree that Rita Khalfon Immigration Consulting may use my data to carry out my immigration process