Approved OMB 1405-0018
Expires 08/31/2004
Estimated Burden 1 hour
See Page 2

U.S. Department of StateNONIMMIGRANT VISA APPLICATION
PLEASE TYPE OR PRINT YOUR ANSWERS IN THE SPACE PROVIDED BELOW EACH ITEM
1. Passport Number

DO NOT WRITE IN THIS SPACE

2. Place of Issuance:
City

CountryState/Province

B-1/B-2 MAX

B-1 MAX

B-2 MAX

OtherMAX
Visa Classification

3. Issuing Country

4. Issuance Date (dd-mmm-yyyy)

5. Expiration Date (dd-mmm-yyyy)

Mult orNumber of Applications
Months

6. Surnames (As in Passport)

Validity
Issued/RefusedByOn

7. First and Middle Names (As in Passport)

Under SEC.

8. Other Surnames Used (Maiden, Religious, Professional, Aliases)

214(b)

221(g)

OtherINA

Reviewed By

10. Date of Birth (dd-mmm-yyyy)

9. Other First and Middle Names Used

11. Place of Birth:City

13. SexMale

12. Nationality

State/ProvinceCountry

15. Home Address (Include apartment number, street, city, state or province, postal zone and country)

14. National Identification Number(If applicable)............................

16. Home Telephone Number............................

FemaleBusiness Phone Number

Mobile/Cell Number...................................................................................................................................................................................................................................................................................................................................................

Fax Number

17. Marital Status
Single (Never Married)
MarriedBusiness Fax Number

Pager Number

18. Spouse's Full Name (Even if divorced or separated. Include maiden name.)

Divorced
Separated
Widowed
20. Name and Address of Present Employer or School
Name:

19. Spouse's DOB (dd-mmm-yyyy)

Address:

21. Present Occupation (If retired, write "retired". If student, 22. When Do You Intend To Arrive In The U.S.?
write "student".)(Provide specific date if known)

23. E-Mail Address

24. At What Address Will You Stay in The U.S.?

BARCODE
25. Name and Telephone Numbers of Person in U.S. Who You Will Be Staying Withor Visiting for Tourism or Business..............................

NameHome Phone

DO NOT WRITE IN THIS SPACE....................................................................................................................................................................................................................................

Business Phone

Cell Phone

26. How Long Do You Intend 27. What is The Purpose of Your Trip?
To Stay in The U.S.?

50 mm x 50 mm
PHOTO
staple or glue photo here

28. Who Will Pay For Your Trip? 29. Have You Ever Been in The U.S.?

Yes

No

WHEN?
FOR HOW LONG?
DS-15602-2003

PREVIOUS EDITIONS OBSOLETE

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30. Have You Ever Been Issued a U.S. Visa?
WHEN?

Yes

No

WHERE?

WHERE?

WHAT TYPE OF VISA?

WHAT TYPE OF VISA?

32. Do You Intend To Work in The U.S.?

Yes

Yes

31. Have You Ever Been Refused a U.S. Visa?
WHEN?

No

33. Do You Intend To Study in The U.S.?

Yes(If YES, give the name and complete address of the school.)(If YES, give the name and complete address of U.S. employer.)No

No

34. Names and Relationships of Persons Traveling With You

35.

Has Your U.S. Visa Ever Been Cancelled or Revoked?

Yes

No

36. Has Anyone Ever Filed an Immigrant Visa Petition on Your Behalf?
Yes
No If Yes, Who?

37. 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.).
Husband/Fiance/YES
NO WifeYESNO Fiancee
YESNO
Brother/
Father/Son/
YES
NO Daughter
SisterMother
38. 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 waiveris obtained in advance). Is any of 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 otherNO
YES
similar legal action? Have you ever unlawfully distributed or sold a controlled substance (drug), or been a prostitute orprocurer 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 orassist others to obtain a 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 ora 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 theU.S. Secretary of State? Have you ever participated in persecutions directed by the Nazi government of Germany; orhave you ever participated in genocide?

YES

NO

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

YES

NO

Have you ever withheld custody of a U.S. citizen child outside the United States from a person granted legal custody bya U.S. court, voted in the United States in violation of any law or regulation, or renounced U.S. citizenship for thepurpose of avoiding taxation?

YESNO

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

YESNO

While a YES answer does not automatically signify ineligibility for a visa, if you answered YES you may be required to personally appear before aconsular officer.
39. Was this Application Prepared by Another Person on Your Behalf?
NoYes(If answer is YES, then have that person complete item 40.)
40. Application Prepared By:
NAME:

Relationship to Applicant:

ADDRESS:
Signature of Person Preparing Form:

DATE (dd-mmm-yyyy)

41. 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 andcorrect to the best of my knowledge 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 understand that possession of a visa does not automatically entitle the bearer to enter the United Statesof America upon arrival at a port of entry if he or she is found inadmissible.
APPLICANT'S SIGNATUREDATE (dd-mmm-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, or enforcement 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 the necessary 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 ofState, A/RPS/DIR, Washington, DC 20520.

DS-156

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