Approved OMB 1405-0018
Expires 08/31/2004
Estimated Burden 1 hour
See Page 2U.S. Department of StateNONIMMIGRANT VISA APPLICATION
PLEASE TYPE OR PRINT YOUR ANSWERS IN THE SPACE PROVIDED BELOW EACH ITEM
1. SURNAMES (As in Passport)

DO NOT WRITE IN THIS SPACE
B-1/B-2 MAX

B-1 MAX

B-2 MAXOTHER

2. FIRST AND MIDDLE NAMES (As in Passport)

MAX
Visa Classification

MULT OR
Number of Applications

3. OTHER SURNAMES USED (Maiden, Religious, Professional, Aliases)
MONTHS

Validity
ISSUED/REFUSED

4. OTHER FIRST AND MIDDLE NAMES USEDBYON

5. DATE OF BIRTH (mm-dd-yyyy)

UNDER SEC.

6. PASSPORT NUMBER

214(b)

221(g)OTHER

7. PLACE OF BIRTHCountry

8. NATIONALITY

INA

REFUSAL REVIEWED BY

State/ProvinceCity

10. NATIONAL IDENTIFICATION NUMBER

9. SEX
MaleFemale

11. MARITAL STATUS
Single (Never Married)
MarriedWidowedDivorced

Separated

12. HOME ADDRESS (Include apartment number, street, city, state or province, postal zone, and country)

13. HOME TELEPHONE NUMBER

14. E-MAIL ADDRESS

15. PRESENT OCCUPATION (If retired, write "retired")

25. DO YOU INTEND TO WORK IN THE U.S.?
YES

16. NAME AND STREET ADDRESS OF PRESENT EMPLOYER OR SCHOOL(Postal box number unacceptable)

17. BUSINESS TELEPHONE NUMBER

18. BUSINESS FAX NUMBERNO

If YES, give name and complete address of U.S. employer.

26. DO YOU INTEND TO STUDY IN THE U.S.
YESNO

19. WHAT IS THE PURPOSE OF YOUR TRIP?

If YES, give name and complete address of school.

20. AT WHAT ADDRESS WILL YOU STAY IN THE U.S.?

27. HAVE YOU EVER BEEN IN THE U.S.?
YESNOWHEN?

21. WHEN DO YOU INTEND TO ARRIVE IN THE U.S.?

FOR HOW LONG?
22. HOW LONG DO YOU INTEND TO STAY IN THE U.S.?

DO NOT WRITE IN THIS SPACE

23. WHO WILL PAY FOR YOUR TRIP?
37 mm x 37 mm
24. NAMES AND RELATIONSHIPS OF PERSONS TRAVELING WITH YOU(NOTE: A separate application for a visa must be made for each traveler, regardless of age.)

PHOTO
staple or glue photo here

DS-15608-2001

PREVIOUS EDITIONS OBSOLETE

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28. HAVE YOU EVER BEEN ISSUED A U.S. VISA?
YES

29. HAVE YOU EVER BEEN REFUSED A U.S. VISA?

NOYESWHEN?

WHEN?

WHERE?

WHERE?

WHAT TYPE OF VISA?

WHAT TYPE OF VISA?

30. HAS YOUR U.S. VISA EVER BEEN CANCELLED OR REVOKED?
YESNO

31. HAS ANYONE EVER FILED AN IMMIGRANT VISA PETITION ON YOURBEHALF?

NOYES

WHEN?

NO

WHERE?
32. ARE ANY OF THE FOLLOWING PERSONS IN THE U.S., OR DO THEY HAVE U.S. LEGAL PERMANENT RESIDENCE OR U.S. CITIZENSHIP?
Mark YES or NO and indicate that person's status in the U.S. (i.e., U.S. legal permanent resident, U.S. citizen, visiting, studying, working, etc.).
NO Husband/
NO Fiance/
NOYES
YES
YES
WifeFiancee
YESNO

Father/MotherYESNOBrother/
SisterSon/
Daughter

33. IMPORTANT: ALL APPLICANTS MUST READ AND CHECK THE APPROPRIATE BOX FOR EACH ITEM.
A visa may not be issued to persons who are within specific categories defined by law as inadmissible to the United States (except when a waiver is obtained in advance). Is anyof the following applicable to you?
Have you ever been arrested or convicted for any offense or crime, even though subject of a pardon, amnesty or other similar legal action?
Have you ever unlawfully distributed or sold a controlled substance (drug), or been a prostitute or procurer for prostitutes?

YESNO

Have you ever been refused admission to the U.S., or been the subject of a deportation hearing, or sought to obtain or assist others to obtaina visa, entry into the U.S., or any other U.S. immigration benefit by fraud or willful misrepresentation or other unlawful means? Have you
attended a U.S. public elementary school on student (F) status or a public secondary school after November 30, 1996 without reimbursing
the school?

YESNO

Do you seek to enter the United States to engage in export control violations, subversive or terrorist activities, or any other unlawful
purpose? Are you a member or representative of a terrorist organization as currently designated by the U.S. Secretary of State? Have you
ever participated in persecutions directed by the Nazi government of Germany; or have you ever participated in genocide?

YESNO

Have you ever violated the terms of a U.S. visa, or been unlawfully present in, or deported from, the United States?

YESNO

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, voted
in the United States in violation of any law or regulation, or renounced U.S. citizenship for the purpose of avoiding taxation?

YES

NO

Have you ever been afflicted with a communicable disease of public health significance or a dangerous physical or mental disorder, or everbeen a drug abuser or addict?

YES

NO

A YES answer does not automatically signify ineligibility for a visa, but if you answered YES to any of the above, or if you have any questions
about the above, a personal appearance at this office is recommended. If an appearance is not possible at this time, attach a statement of facts
in your case to this application.
34. WAS THIS APPLICATION PREPARED BY ANOTHER PERSON ON YOUR BEHALF?

YES

NO

(If answer is YES, then have that person complete item 35
35. Application Prepared By: NAME:
ADDRESS:
Relationship to Applicant:Signature of Person Preparing Form:

DATE (mm-dd-yyyy)

36. I certify that I have read and understood all the questions set forth in this application and the answers I have furnished on this form are true and correct to the best of myknowledge and belief. I understand that any false or misleading statement may result in the permanent refusal of a visa or denial of entry into the United States. I understandthat possession of a visa does not automatically entitle the bearer to enter the United States of America upon arrival at a port of entry if he or she is found inadmissible.

APPLICANT'S SIGNATUREDATE (mm-dd-yyyy)
Privacy Act and Paperwork Reduction Act Statements
INA Section 222(f) provides that visa issuance and refusal records shall be considered confidential and shall be used only for the formulation, amendment, administration, orenforcement of the immigration, nationality, and other laws of the United States. Certified copies of visa records may be made available to a court which certifies that the information
contained in such records is needed in a case pending before the court.
Public reporting burden for this collection of information is estimated to average 1 hour per response, including time required for searching existing data sources, gathering thenecessary data, providing the information required, and reviewing the final collection. You do not have to provide the information unless this collection displays a currently valid OMB
number. Send comments on the accuracy of this estimate of the burden and recommendations for reducing it to: U.S. Department of State, A/RPS/DIR, Washington, D.C. 20520-1849.

DS-156

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