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Sample Form DS-160 for USA Visa Application

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( Please fill Each and Every details, as required )

Edit Personal Information

SHAH HARESH BHAGWANDAS


Name Provided:
(Exctaly same as per Passport)
Full Name in Native Alphabet: DOES NOT APPLY
Other Names Used: NO
Telecode Name Used: NO
Sex: MALE
Marital Status: MARRIED
Date of Birth: 28 JANUARY 1946
Country/Region of Birth: SURAT, GUJARAT, INDIA
Country/Region of Origin
INDIA
(Nationality):
Do you hold or have you held any
nationality other than the one NO
indicated above on nationality?
National Identification Number: DOES NOT APPLY
U.S. Social Security Number: DOES NOT APPLY
U.S. Taxpayer ID Number: DOES NOT APPLY
Edit Address and Phone
Information
Home Address: 23-24 OM SOCIETY
NEAR GATE
City: ABCD
State/Province: MUMBAI
Postal Zone/ZIP Code: 400000
Country/Region: INDIA
Same Mailing Address? YES
Primary Phone Number: 022-1234567
Secondary Phone Number: 91-912345678
Work Phone Number: 022- 123456
Email Address: ABCD@rediff.com
Edit Passport/Travel Document Information
Passport/Travel Document Type: REGULAR
Passport/Travel Document
E9123456
Number:
Passport Book Number: DOES NOT APPLY
Country/Authority that Issued
INDIA
Passport/Travel Document:
City where issued: MUMBAI
Country/Region where issued: INDIA
Issuance Date: 07 JULY 2004
Expiration Date: 06 JULY 2014
Have you ever lost a passport or
NO
had one stolen?

Edit Travel Information


The List of Purposes of Trip to the U.S.

TEMP. BUSINESS PLEASURE


Purpose of Trip to the U.S. (1):
VISITOR (B)
TOURISM/MEDICAL
Specify:
TREATMENT (B2)

Have you made specific travel


NO
plans?
Intended Date of Arrival: 01 DECEMBER 2013
Intended Length of Stay in U.S.: 4 WEEK(S)

Address where you will stay in the 1234 BLUFF DRIVE,


U.S.: NEW YORK
NY 22334

Person/Entity Paying for Your Trip: SELF


Edit Travel Companions
Information
Other Persons Traveling with You: YES
Are you traveling as part of a NO
group or organization?
Persons Traveling with You:

Name (1): JARIWALA , BHANUBEN


Relationship to You: SPOUSE

Edit Previous U.S. Travel


Information
Have you ever been in the U.S.? NO
Have you ever been issued a U.S.
NO
visa?
Have you ever been refused a
U.S. Visa, or been refused
admission to the United States, or YES
withdrawn your application for
admission at the port of entry?
Explain: 10 JAN 2008 - B2
Has anyone ever filed an
immigrant petition on your behalf
NO
with the United States Citizenship
and Immigration Services?

Edit U.S. Point of Contact Information


Contact Person Name in the U.S.: MRS A B PATEL
Organization Name in the U.S.: DOES NOT APPLY
Relationship to You: SISTER
1234 DRIVE,
U.S. Contact Address: NEW YORK
NY 23834

Phone Number: 123 456 8023


Email Address: Ka1234@gmail.com

Edit Family Information: Relatives


Father's Surnames: JARIWALA
Father's Given Names: LAXMANDAS
Father's Date of Birth: 03 APRIL 1918
Is your father in the U.S.? NO
Mother's Surnames: JARIWALA
Mother's Given Names: RADHABEN
Mother's Date of Birth: 21 JULY 1922
Is your mother in the U.S.? NO
Do you have any immediate
relatives, not including parents in NO
the U.S.?
Do you have any other relatives
NO
in the United States?
Edit Family Information: Spouse
Spouse's Full Name: JARIWALA, MEENA
Spouse's Date of Birth: 07 AUGUST 1949
Spouse's Country/Region of
INDIA
Origin (Nationality):
Spouse's City of Birth: SURAT
Spouse's Country/Region of Birth: INDIA
Spouse’s Address: SAME AS HOME ADDRESS

Edit Present Work


Information
Primary Occupation: BUSINESS
Present Employer or School
ABCD INDUSTRIES
Name:
Present Employer or School
FULL ADDRESS
Address:
MUMBAI
City: MUMBAI
State/Province: MAHARASHTRA
Postal Zone/Zip Code: 400000
Country/Region: INDIA
Work Phone Number: 022-1234567
Monthly Salary in Local Currency DOES NOT APPLY
(if employed):
PARTNER OF M/S ABCD
Briefly Describe your Duties:
INDUSTRIES
Edit Previous Work
Information
Were you previously employed? NO
Have you attended any
educational institutions at a YES
secondary level or above?

Name of Institution (1): UNIVERSITY OF BARODA


Address of Institution: BARODA
City: BRODA
State/Province: DOES NOT APPLY
Postal Zone/ZIP Code: 123456
Country/Region: INDIA
POST GRADUATE DIPLOMA IN
Course of Study: TECHNICAL TECHNOLOGY -
TEXTILE PROCESSING
Date of Attendance From: 10 AUGUST 1970
Date of Attendance To: 07 JULY 1971
THE MAHARAJA SAYAJIRAO
UNIVERSITY - FACULTY OF
Name of Institution (2):
TECHNOLOGY AND
ENGINEERING
Address of Institution: KALABHAVAN
City: BARODA
State/Province: GUJARAT
Postal Zone/ZIP Code: DOES NOT APPLY
Country/Region: INDIA
BACHELOR OF TEXTILE
Course of Study:
(TECHNOLOGY)
Date of Attendance From: 10 JUNE 1965
Date of Attendance To: 10 MAY 1970

Edit Additional Information


Do you belong to a clan or tribe? NO
Provide a List of Languages You Speak:

Language Name: (1): ENGLISH


Language Name: (2): HINDI
Language Name: (3): GUJARATI

Have you traveled to any


countries within the last five YES
years?

Country Visited (1): AUSTRIA


Country Visited (2): CHINA

Country Visited (3): UNITED KINGDOM

Have you belonged to,


contributed to, or worked for any
NO
professional, social, or charitable
organization?
Do you have any specialized skills
or training, including firearms,
NO
explosives, nuclear, biological, or
chemical experience?
Have you ever served in the
NO
military?
Have you ever served in, been a
member of, or been involved with
a paramilitary unit, vigilante unit, NO
rebel group, guerrilla group, or
insurgent organization?