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Consular Electronic Application Center - Print Application

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Nonimmigrant Visa Application


Application - Sensitive But Unclassified(SBU)
Photo Provided:

SAMPLE - IMMIHELP.COM

Confirmation Number:

Personal, Address, Phone, and Passport Information


Name Provided:
Full Name in Native Language:

Other Names Used:


Other Name (1) :

GUPTA , RAMESH
DOES NOT APPLY
YES
NONE , RAMESHBHAI

Sex:
Marital Status:
Date of Birth:
Place of Birth:
Nationality:
Other Nationalities:

MALE
MARRIED
01 JANUARY 1945
MUMBAI , MAHARASHTRA , INDIA
INDIA
NO

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?
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?

DOES NOT APPLY


DOES NOT APPLY
DOES NOT APPLY
34 SHANKAR LANE
BORIVALI
MAHARASHTRA
400034
INDIA
YES
91-22-5555-1111
91-22-5555-1111
91-22-5555-1111
91-22-5555-1111
suresh@yahoo.com
A9783434
DOES NOT APPLY
INDIA
MUMBAI
MAHARASHTRA
INDIA
10 JANUARY 2009
28 JANUARY 2019
NO

Travel Information

Consular Electronic Application Center - Print Application

Principal Applicant?

YES

Purpose of Your Trip to U.S.


Purpose (1) :

TOURIST/PERSONAL TRAVEL VISITOR (B2)

Intended Date of Arrival:


Intended Length of Stay in U.S.:
Address where you will stay in the U.S:

29 JUNE 2010
6 MONTH(S)
123 PARK AVENUE
EDISON, NEW JERSEY 08817
Person/Entity Paying for Your Trip:
OTHER PERSON
Name of Person Paying for Your Trip:
GUPTA , RAHUL
Telephone:
732-555-1212
Email Address:
rahul@yahoo.com
Relationship to You:
CHILD
Is the address of the party paying for your trip the NO
same as your Home or Mailing Address?
Paying Address:
123 PARK AVENUE
City:
EDISON
State/Province:
NJ
Postal Zone/ZIP Code:
08817
Country:
UNITED STATES OF AMERICA

Other Persons Traveling with You:

YES

Are you traveling as part of a group or


organization?
Persons Traveling with You:
Name (1) :
Relationship to You:

NO

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?

NO
NO
NO

GUPTA , RAMILA
SPOUSE

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:

GUPTA, RAHUL
DO NOT KNOW
RELATIVE
123 PARK AVENUE
EDISON, NEW JERSEY 08817
(732)555-1212
rahul@yahoo.com

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.?
Relative Name (1) :
Relationship to you:
Status:
Spouse's
Spouse's
Spouse's
Spouse's

Full Name:
Date of Birth:
Nationality:
City of Birth:

GUPTA
AMRIT
10 JANUARY 1933
NO
GUPTA
SAVITA
10 FEBRUARY 1934
NO
YES
GUPTA , RAHUL
CHILD
U.S. CITIZEN
GUPTA , RAMILA
29 MARCH 1947
INDIA
DELHI

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Consular Electronic Application Center - Print Application

Spouse's Country of Birth:


Spouses Address:

INDIA
SAME AS HOME 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:

BUSINESS
STAR BAZAAR
2345 KHAR LANE
MUMBAI
MAHARASHTRA
400011
INDIA
45,000
SALESMAN

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?
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?

NO
NO

NO
NO

NO

NO

NO
NO

NO

NO

NO
NO
NO
NO

NO

NO

Have you ever withheld custody of a U.S. citizen NO


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 NO

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Consular Electronic Application Center - Print Application

any law or regulation?


Have you ever renounced United States
citizenship for the purpose of avoiding taxation?

NO

Location Information
Current Location: 080%$,,1',$

Preparer of Application:
Did anyone assist you in filling out this
application?

NO

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