USA Visa Application Form

Personal Information

Surname (as in Passport)

Sex

Date of Birth

Place of Birth

Nationality

Marital Status

Spouse Name

Spouse Date of Birth

Spouse Place of Birth

Contact Information

Home Address

City

State/Province

Country

Home Phone Number

Work Phone Number

Mobile Phone Number

Email Address

Passport Information

Passport Number

Country/Authority that Issued Passport

City Where Issued

Issuance Date

Expiration Date

Have you ever lost a passport or had one stolen?

Yes No

Travel Information

Purpose of Your Trip to U.S.

Specific Travel Plan

Intended Date of Arrival

Intended Length of Stay in U.S.

Address where you will stay in the U.S.

Who is paying for your trip?

Previous U.S. Travel

Have you ever been in the U.S.?

Yes No

When? (With Date)

U.S. Contact Information

Contact Person Name in the U.S.

Organization Name in the U.S.

Relationship to You

U.S. Contact Address with Zip code

Phone Number

Email Address

Family Information

Father's Surnames

Father's Given Names

Mother's Surnames

Mother's Given Names

Additional Information

Do you belong to a clan or tribe?

Yes No

Clan or Tribe Name

Have you traveled to any countries within the last five years?

Yes No

If Yes! Name countries