Have you ever held a passport other than the passport listed in your visa application?

Have you travelled to any country (other than your country of residence) in the last 15 years? Yes No

If yes, provide details for each trip that is not already included on your visa application (DS-156, DS-160, or DS-260), including locations visited, date visited,

source of funds, and length of stay.

Passport and Travel History

Personal Information

Surname(s) Given Name(s)

Date of Birth (mm-dd-yyyy) Visa Type/Classification

If yes, provide the following information.

Yes No

Country of Issuance Passport Number

Surname(s) Given Name(s) Date of Birth (mm-dd-yyyy)

Relatives

Siblings (brothers and sisters) - Provide the full name(s) and date of birth of any sibling (full, half, step, adopted), living or deceased.

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SUPPLEMENTAL QUESTIONS FOR VISA APPLICANTS

Approved OMB 1405-0226

Expires XX/XX/20XX

Estimated Burden 55 Minutes

U.S. Department of State

General Instructions

 • If you are unsure of the answer to a question, please provide a response to the best of your knowledge. For example, if you are unsure of an exact address,

provide the city, state, and street name if you can recall them. U.S. Department of State will consider all the information derived from the form in its entirety. 

 • Failure to answer every question will not necessarily preclude visa issuance, as the application is considered in its entirety.

 • If you believe a particular question does not apply to you or your circumstances, please write "not applicable" or "N/A." 

 • If you need more space to respond to a question, please write the rest of your response on a separate sheet of paper.

 • Aside from your name, date of birth, and visa classification, please only provide information not included in your current visa application. For example, if all

of your children are listed in your current visa application (Form DS-160 or DS-260), you do not need to list them again.

CONFIDENTIALITY STATEMENT

AUTHORITIES: The information on this form is requested pursuant to Section 212(a) and 221 and as required by Section 222 of the Immigration and Nationality

Act. Section 222(f) provides that the records of the Department of State and of diplomatic and consular offices of the United States pertaining to the issuance

and refusal of visas or permits to enter the United States 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 such records may, in the discretion of the Secretary of

State, be made available to a court provided the court certifies that the information contained in such records is needed in a case pending before the court.

PURPOSE: The U.S. Department of State uses the information provided on this form to determine an individual’s eligibility for a U.S. visa. Individuals who fail to

submit this form or who do not provide all the requested information may be denied a U.S. visa. Although furnishing this information is voluntary, failure to

provide this information may delay or prevent the processing of an individual visa application.
Surname(s) Given Name(s) Date of Birth (mm-dd-yyyy)

Relatives - Continued

Spouse - Provide the full name(s) of any current or previous spouse or civil/domestic partner, living or deceased.

Address and Contact Information

Address - Provide all addresses where you have lived during the last 15 years, if not already provided in your application.

Dates of Residence (mm-dd-yyyy)

Street Address 1

Address 1 Address 2

Street Address 2

City State/Province

Postal Zone/Zip Code Country/Region

Dates of Residence (mm-dd-yyyy)

Street Address 1

Street Address 2

City State/Province

Postal Zone/Zip Code Country/Region

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Surname(s) Given Name(s)

Children - Provide the full name(s) and date of birth of any child (minor and adult), living or deceased. Children includes natural children, step-children, and adopted children.

Date of Birth (mm-dd-yyyy)

Address - Provide all addresses where you have lived during the last 15 years, if not already provided in your application.

Dates of Residence (mm-dd-yyyy)

Street Address 1

Address 3 Address 4

Street Address 2

City State/Province

Postal Zone/Zip Code Country/Region

Dates of Residence (mm-dd-yyyy)

Street Address 1

Street Address 2

City State/Province

Postal Zone/Zip Code Country/Region
Employment History

Provide the following information on all employment in the last fifteen years, if not already provided in your application.

Dates of Employment (mm-dd-yyyy)

Street Address 1 Street Address 1

Street Address 2

City State/Province

Postal Zone/Zip Code Country/Region

Dates of Employment (mm-dd-yyyy)

Street Address 2

City State/Province

Postal Zone/Zip Code Country/Region

Employer Name Employer Name

Telephone Number

Job Title

Job Description

Telephone Number

Job Title

Job Description

I understand all the information I have provided in, or in support of, this application may be provided to other U.S. government agencies authorized to use such information for

purposes including enforcement of the laws of the United States. I understand all of the information contained in this form and I certify under penalty of perjury under the laws of

the United States of America that the foregoing is complete, true, and correct. I understand that any willfully false or misleading statement or willful concealment of a material fact

made by me herein may result in refusal of the visa, denial of admission to the United States, and, may subject me to criminal prosecution and/or removal from the United States.

Date (mm-dd-yyyy)

PAPERWORK REDUCTION ACT STATEMENT

Public reporting burden for this collection of information is estimated to average 55 minutes per response, including time required for searching existing data

sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final collection. You do not have to

supply this information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy of this burden estimate

and/or recommendations for reducing it, please send them to: PRA_BurdenComments@state.gov. 

Applicant's Signature

For use by United States embassy or consulate official only: DS-160/DS-260 Barcode Number

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