US Visa Application Form

Visas, Immigration & Nationality

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US Visa Application

Please complete, in as much detail as possible, the below US Visa Application form in order to start your application for a visa to the United States Of America.

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Step 1 of 15

Please select the visa application type

VISA ROUTE*

ESTA (Electronic System for Travel Authorisation)

Other

United States of America IMMIGRATION

Please complete the form below.

Please also note that it is very important to enter accurate data, which will be needed in completing your free assessment.

Surnames*

Enter all surnames as listed in your passport. If only one name is listed in your passport, enter that Surname.

Given Names*

If your passport does not include a given name, please enter ‘FNU' in Given Names.

Full Name in Native Alphabet

HAVE YOU EVER USED OTHER NAMES (I.E., MAIDEN, RELIGIOUS, PROFESSIONAL, ALIAS, ETC.)?

Yes

Other Surnames Used (maiden, religious, professional, aliases, etc.) and Other Given Names Used

DO YOU HAVE A TELECODE THAT REPRESENTS YOUR NAME?

Yes

Other Surnames Used (maiden, religious, professional, aliases, etc.) and Other Given Names Used*

SEX*

Male

Female

Marital Status*

DATE OF BIRTH

DD dash MM dash YYYY

Place of Birth*

Country of Birth*

US Contact details

IS YOUR TRAVEL TO THE US OCCURRING IN TRANSIT TO ANOTHER COUNTRY?

Yes

U.S. POINT OF CONTACT INFORMATION

Name

Address*

Street Address Address Line 2 City State Zip/ Postal Code

Telephone / Mobile Number

ADDRESS WHILE IN THE U.S.

EMERGENCY CONTACT INFORMATION IN OR OUT OF THE U.S.

Family Name*

First (Given) Name*

Emergency Contact Email Address*

Contact Number*

ELIGIBILITY QUESTIONS

DO YOU HAVE A PHYSICAL OR MENTAL DISORDER; OR ARE YOU A DRUG ABUSER OR ADDICT; OR DO YOU CURRENTLY HAVE ANY OF THE FOLLOWING DISEASES (COMMUNICABLE DISEASES ARE SPECIFIED PURSUANT TO SECTION 361(B) OF THE PUBLIC HEALTH SERVICE ACT):* 1) CHOLERA 2) DIPHTHERIA 3) TUBERCULOSIS, INFECTIOUS 4) PLAGUE 5) SMALLPOX 6) YELLOW FEVER 7) VIRAL HEMORRHAGIC FEVERS, INCLUDING EBOLA, LASSA, MARBURG, CRIMEAN-CONGO 8) SEVERE ACUTE RESPIRATORY ILLNESSES CAPABLE OF TRANSMISSION TO OTHER PERSONS AND LIKELY TO CAUSE MORTALITY.*

Yes

HAVE YOU EVER BEEN ARRESTED OR CONVICTED FOR A CRIME THAT RESULTED IN SERIOUS DAMAGE TO PROPERTY, OR SERIOUS HARM TO ANOTHER PERSON OR GOVERNMENT AUTHORITY?*

Yes

HAVE YOU EVER VIOLATED ANY LAW RELATED TO POSSESSING, USING, OR DISTRIBUTING ILLEGAL DRUGS?*

Yes

DO YOU SEEK TO ENGAGE IN OR HAVE YOU EVER ENGAGED IN TERRORIST ACTIVITIES, ESPIONAGE, SABOTAGE, OR GENOCIDE?*

Yes

HAVE YOU EVER COMMITTED FRAUD OR MISREPRESENTED YOURSELF OR OTHERS TO OBTAIN, OR ASSIST OTHERS TO OBTAIN, A VISA OR ENTRY INTO THE UNITED STATES?*

Yes

ARE YOU CURRENTLY SEEKING EMPLOYMENT IN THE UNITED STATES OR WERE YOU PREVIOUSLY EMPLOYED IN THE UNITED STATES WITHOUT PRIOR PERMISSION FROM THE U.S. GOVERNMENT?*

Yes

HAVE YOU EVER BEEN DENIED A U.S. VISA YOU APPLIED FOR WITH YOUR CURRENT OR PREVIOUS PASSPORT, OR HAVE YOU EVER BEEN REFUSED ADMISSION TO THE UNITED STATES OR WITHDRAWN YOUR APPLICATION FOR ADMISSION AT A U.S. PORT OF ENTRY?*

Yes

HAVE YOU EVER STAYED IN THE UNITED STATES LONGER THAN THE ADMISSION PERIOD GRANTED TO YOU BY THE U.S. GOVERNMENT?*

Yes

HAVE YOU TRAVELED TO, OR BEEN PRESENT IN IRAQ, SYRIA, IRAN, SUDAN, LIBYA, SOMALIA OR YEMEN ON OR AFTER MARCH 1, 2011?*

Yes

Personal Information 2

Country/Region of Origin (Nationality)*

DO YOU HOLD OR HAVE YOU HELD ANY NATIONALITY OTHER THAN THE ONE INDICATED ABOVE ON NATIONALITY?*

Yes

Country/Region of Origin (Nationality)

ARE YOU A PERMANENT RESIDENT OF A COUNTRY/REGION OTHER THAN YOUR COUNTRY/REGION OF ORIGIN (NATIONALITY) INDICATED ABOVE?

Yes

Other Permanent Resident Country/Region

National Identification Number

If this does not apply to you please type N/A

U.S. Social Security Number

If this does not apply to you please type N/A

U.S. Taxpayer ID Number

If this does not apply to you please type N/A

Address and Phone Information

Home Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

IS YOUR MAILING ADDRESS THE SAME AS YOUR HOME ADDRESS?*

Yes

Provide your mailing address:*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Gender*

Primary Phone Number*

Secondary Phone Number

Work Phone Number

Your Email Address*

Passport Information

Passport/Travel Document Type*

Passport/Travel Document Number*

Passport Book Number

Country/Authority that Issued Passport/Travel Document*

Where was the Passport/Travel Document Issued?*

ISSUANCE DATE*

DD dash MM dash YYYY

EXPIRATION DATE*

DD dash MM dash YYYY

HAVE YOU EVER LOST A PASSPORT OR HAD ONE STOLEN?

Yes

Provide the following information:

Passport/Travel Document Number

Country/Authority that Issued Passport/Travel Document*

Explain

Travel Information

NOTE: Provide the following information concerning your travel plans.

Purpose of Trip to the U.S.*

Please specify

INTENDED DATE OF ARRIVAL

DD dash MM dash YYYY

Intended Length of Stay in U.S.

Address Where You Will Stay in the U.S.

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Person/Entity Paying for Your Trip

Telephone Number*

Person/Entity Email Address

Relationship to You

IS THE ADDRESS OF THE PARTY PAYING FOR YOUR TRIP THE SAME AS YOUR HOME OR MAILING ADDRESS?

Yes

Travel Companions Information

NOTE: Provide the following travel companion information.

ARE THERE OTHER PERSONS TRAVELING WITH YOU?*

Yes

ARE YOU TRAVELING AS PART OF A GROUP OR ORGANIZATION?*

Yes

Group Name*

Name of Person Traveling With You*

Relationship to You*

Previous U.S. Travel Information

NOTE: Provide the following previous U.S. travel information. Provide complete and accurate information to all questions that require an explanation.

HAVE YOU EVER BEEN IN THE U.S.?

Yes

Provide information on your last five U.S. visits

DATE ARRIVED

DD dash MM dash YYYY

DO YOU OR DID YOU EVER HOLD A U.S. DRIVER’S LICENSE?

Yes

Driver's License Number

HAVE YOU EVER BEEN REFUSED A U.S. VISA, OR BEEN REFUSED ADMISSION TO THE UNITED STATES, OR WITHDRAWN YOUR APPLICATION FOR ADMISSION AT THE PORT OF ENTRY?

Yes

Explain

HAS ANYONE EVER FILED AN IMMIGRANT PETITION ON YOUR BEHALF WITH THE UNITED STATES CITIZENSHIP AND IMMIGRATION SERVICES?

Yes

Explain

U.S. Point of Contact Information

Contact Person or Organization in the United States

Full name

Relationship to You*

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Family Information: Relatives

NOTE: Please provide the following information concerning your biological parents. If you are adopted, please provide the following information on your adoptive parents.

Father's Full Name and Date of Birth

Surnames

Given Names

DATE OF BIRTH

DD dash MM dash YYYY

IS YOUR FATHER IN THE U.S.?

Yes

Father's Status

Mother's Full Name and Date of Birth

Surnames

Given Names

DATE OF BIRTH

DD dash MM dash YYYY

IS YOUR MOTHER IN THE U.S.?

Yes

Father's Status

DO YOU HAVE ANY IMMEDIATE RELATIVES, NOT INCLUDING PARENTS, IN THE UNITED STATES?

Yes

Full name

Relationship to You*

Present Work/Education/Training Information

NOTE: Provide the following information concerning your current employment or education.

Primary Occupation

Present Employer or School Name

Present employer or school address:

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Monthly Income in Local Currency (if employed)

Briefly describe your duties:

Security and Background: Part 1

NOTE: Provide the following security and background information. Provide complete and accurate information to all questions that require an explanation. 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). Are any of the following applicable to you? While a YES answer does not automatically signify ineligibility for a visa, if you answer YES you may be required to personally appear before a consular officer.

DO YOU HAVE A COMMUNICABLE DISEASE OF PUBLIC HEALTH SIGNIFICANCE? (COMMUNICABLE DISEASES OF PUBLIC SIGNIFICANCE INCLUDE CHANCROID, GONORRHEA, GRANULOMA INGUINALE, INFECTIOUS LEPROSY, LYMPHOGRANULOMA VENEREUM, INFECTIOUS STAGE SYPHILIS, ACTIVE TUBERCULOSIS, AND OTHER DISEASES AS DETERMINED BY THE DEPARTMENT OF HEALTH AND HUMAN SERVICES.)

Yes

Explain*

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?

Yes

Explain*

ARE YOU OR HAVE YOU EVER BEEN A DRUG ABUSER OR ADDICT?

Yes

Explain*

HAVE YOU EVER BEEN ARRESTED OR CONVICTED FOR ANY OFFENSE OR CRIME, EVEN THOUGH SUBJECT OF A PARDON, AMNESTY, OR OTHER SIMILAR ACTION?

Yes

Explain*

HAVE YOU EVER VIOLATED, OR ENGAGED IN A CONSPIRACY TO VIOLATE, ANY LAW RELATING TO CONTROLLED SUBSTANCES?

Yes

Explain*

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?

Yes

Explain*

HAVE YOU EVER BEEN INVOLVED IN, OR DO YOU SEEK TO ENGAGE IN, MONEY LAUNDERING?

Yes

Explain*

HAVE YOU EVER COMMITTED OR CONSPIRED TO COMMIT A HUMAN TRAFFICKING OFFENSE IN THE UNITED STATES OR OUTSIDE THE UNITED STATES?

Yes

Explain*

HAVE YOU EVER KNOWINGLY AIDED, ABETTED, ASSISTED OR COLLUDED WITH AN INDIVIDUAL WHO HAS COMMITTED, OR CONSPIRED TO COMMIT A SEVERE HUMAN TRAFFICKING OFFENSE IN THE UNITED STATES OR OUTSIDE THE UNITED STATES?

Yes

Explain*

ARE YOU THE SPOUSE, SON, OR DAUGHTER OF AN INDIVIDUAL WHO HAS COMMITTED OR CONSPIRED TO COMMIT A HUMAN TRAFFICKING OFFENSE IN THE UNITED STATES OR OUTSIDE THE UNITED STATES AND HAVE YOU WITHIN THE LAST FIVE YEARS, KNOWINGLY BENEFITED FROM THE TRAFFICKING ACTIVITIES?

Yes

Explain*

Security and Background: Part 2

DO YOU SEEK TO ENGAGE IN ESPIONAGE, SABOTAGE, EXPORT CONTROL VIOLATIONS, OR ANY OTHER ILLEGAL ACTIVITY WHILE IN THE UNITED STATES?

Yes

Explain*

DO YOU SEEK TO ENGAGE IN TERRORIST ACTIVITIES WHILE IN THE UNITED STATES OR HAVE YOU EVER ENGAGED IN TERRORIST ACTIVITIES?

Yes

Explain*

HAVE YOU EVER OR DO YOU INTEND TO PROVIDE FINANCIAL ASSISTANCE OR OTHER SUPPORT TO TERRORISTS OR TERRORIST ORGANIZATIONS?

Yes

Explain*

ARE YOU A MEMBER OR REPRESENTATIVE OF A TERRORIST ORGANIZATION?

Yes

Explain*

HAVE YOU EVER ORDERED, INCITED, COMMITTED, ASSISTED, OR OTHERWISE PARTICIPATED IN GENOCIDE?

Yes

Explain*

HAVE YOU EVER COMMITTED, ORDERED, INCITED, ASSISTED, OR OTHERWISE PARTICIPATED IN TORTURE?

Yes

Explain*

HAVE YOU COMMITTED, ORDERED, INCITED, ASSISTED, OR OTHERWISE PARTICIPATED IN EXTRAJUDICIAL KILLINGS, POLITICAL KILLINGS, OR OTHER ACTS OF VIOLENCE?

Yes

Explain*

HAVE YOU EVER ENGAGED IN THE RECRUITMENT OR THE USE OF CHILD SOLDIERS?

Yes

Explain*

HAVE YOU, WHILE SERVING AS A GOVERNMENT OFFICIAL, BEEN RESPONSIBLE FOR OR DIRECTLY CARRIED OUT, AT ANY TIME, PARTICULARLY SEVERE VIOLATIONS OF RELIGIOUS FREEDOM?

Yes

Explain*

HAVE YOU EVER BEEN DIRECTLY INVOLVED IN THE ESTABLISHMENT OR ENFORCEMENT OF POPULATION CONTROLS FORCING A WOMAN TO UNDERGO AN ABORTION AGAINST HER FREE CHOICE OR A MAN OR A WOMAN TO UNDERGO STERILIZATION AGAINST HIS OR HER FREE WILL?

Yes

Explain*

HAVE YOU EVER BEEN DIRECTLY INVOLVED IN THE COERCIVE TRANSPLANTATION OF HUMAN ORGANS OR BODILY TISSUE?

Yes

Explain*

Security and Background: Part 3

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?

Yes

Explain*

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?

Yes

Explain*

HAVE YOU VOTED IN THE UNITED STATES IN VIOLATION OF ANY LAW OR REGULATION?

Yes

Explain*

HAVE YOU EVER RENOUNCED UNITED STATES CITIZENSHIP FOR THE PURPOSES OF AVOIDING TAXATION?

Yes

Explain*

TERMS & CONDITIONS*

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