Full Name – Surname

Full Name – Given Names

Other Names Used (maiden names, aliases)

Marital Status
SingleMarriedDivorcedWidowedOther

Date of Birth

Place of Birth – City

Place of Birth – State/Province

Place of Birth – Country

Nationality – Current

Nationality – Previous (if any)

National Identification Number (if applicable)

Purpose of Trip (e.g., B-1, B-2, etc.)

Intended Date of Arrival

Intended Date of Departure

U.S. Address – Street

U.S. Address – City

U.S. Address – State

U.S. Address – Zip (if known)

Person/Entity Paying for the Trip (Name)

Relationship to Applicant (if applicable)

Are you traveling with someone else?
YesNo

If yes, list names, relationship, and passport numbers

Have you been to the U.S. before?
YesNo

If yes, dates of travel and purpose

Previous U.S. Visa Applications – issued or denied?
YesNo

Details on previous visa decisions

Contact Name or Organization

Relationship to You

Phone Number

Email

U.S. Address (Street, City, State)

Father’s Full Name

Father’s Date of Birth

Father’s Current Location

Mother’s Full Name

Mother’s Date of Birth

Mother’s Current Location

Do you have immediate relatives in the U.S.?
YesNo

If yes, list names, relationship, immigration status, and city/state

Current Occupation

Employer/School Name

Employer/School Address

Phone Number

Monthly Salary (local currency)

Job Duties

Previous Employment (past 5 years): Names, positions, dates

Education: School names, dates attended, fields of study

Communicable diseases, physical or mental disorders?
YesNo

If yes, explain

Drug use or addiction?
YesNo

If yes, explain

Arrested or convicted of a crime?
YesNo

If yes, explain

Terrorist activities or affiliations?
YesNo

If yes, explain

Espionage or sabotage involvement?
YesNo

If yes, explain

Immigration violations (overstay, fraud)?
YesNo

If yes, explain

Involvement in human trafficking, money laundering, etc.?
YesNo

If yes, explain

Social Media – List usernames and platforms (past 5 years)

Countries visited in the past 5 years

Military Service – Country, branch, rank, specialty

Memberships – clubs, orgs, etc.

Specialized Skills – firearms, explosives, nuclear, etc.