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Client Information – USA Visa Checklist
Step 1 of 2
50%
Personal Information of Principal Applicant
Surname:
*
GIven Name:
*
Full Name:
*
Have you used any other name before?
*
Select
Yes
No
Please specify your alternative name:
Do you have a telecode that represnts your name?
*
Select
Yes
No
Please specify your Telecode name:
Date of Birth
*
City, Country of Birth
*
Email
*
Phone Number
*
Marital Status of the Applicant
*
Select
Single
Divorced
Married
Common Law Marriage
Widowed
Legally Seperated
Nationality (Country/Region of Origin)
Do you hold or have you held any nationality other than the one indicated above on nationality?
*
Select
Yes
No
Nationality (Other Country/Region of Origin)
Do you hold a passport for the other country/region of origin (nationality) indicated above?
*
Select
Yes
No
Please Provide the Passport Number:
*
Are you a permanent resident of a country/region other than your country/region of origin (nationality) indicated above?
*
Select
Yes
No
Other Permanent Resident Country/Region:
*
National Identification Number :
U.S. Social Security Number:
U.S. Taxpayer ID Number:
Travel Information
Purpose of Trip to the U.S:
*
Have you made specific travel plans?
*
Select
Yes
No
Intended Date of Arrival:
*
Intended Length of Stay in U.S(Mention Days)
*
Date of Arrival in U.S:
*
Arrival Flight (if known)
Arrival City:
*
Date of Departure from U.S:
*
Departure Flight (if known):
*
Departure City:
*
Provide the locations you plan to visit in the U.S.:
*
Address Where You Will Stay in the U.S:
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Saint Martin
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Country
Person/Entity Paying for Your Trip:
*
Are there other persons traveling with you?
*
Select
Yes
No
Are you traveling as part of a group or organization?
*
Select
Yes
No
Enter the name of the group you are traveling with:
*
Enter person(s) traveling with you:
First Name
Last Name
Relationship with Person
Previous U.S. Travel Information
Have you ever been in the U.S.?
*
Select
Yes
No
Provide Information:
Date Arrived
Length of Stay
Do you or did you ever hold a U.S. Driver’s License?
*
Select
Yes
No
Provide the Driver's License Number:
*
State of Driver's License:
*
Have you ever been issued a U.S. Visa?
*
Select
Yes
No
Date Last Visa Was Issued
*
Visa Number
*
Are you applying for the same type of visa?
*
Select
Yes
No
Are you applying in the same country or location where the visa above was issued, and is this country or location your place of principal of residence?
*
Select
Yes
No
Have you been ten-printed?
*
Select
Yes
No
Has your U.S. Visa ever been lost or stolen?
*
Select
Yes
No
Enter year visa was lost or stolen:
Please Provide Information:
Has your U.S. Visa ever been cancelled or revoked?
*
Select
Yes
No
Please Provide Information:
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?
*
Select
Yes
No
Please Provide Information:
Have you ever been denied travel authorization by the Department of Homeland Security through the Electronic System for Travel Authorization (ESTA)?
*
Select
Yes
No
Please Provide Information:
Has anyone ever filed an immigrant petition on your behalf with the United States Citizenship and Immigration Services?
*
Select
Yes
No
Please Provide Information:
Address and Phone Information
Home Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Saint Martin
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Country
Is your Mailing Address the same as your Home Address?
*
Select
Yes
No
Mailing Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Saint Martin
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Country
Phone Number
Have you used any other phone numbers in the last five years?
*
Select
Yes
No
Please list below
Email
Have you used any other email addresses in the last five years?
*
Select
Yes
No
Please list below
Do you have a social media presence? (Ex: FaceBook, LinkedIn)
*
Select
Yes
No
Please list below
Social Media Name
Identity
Have you ever lost a passport or had one stolen?
*
Select
Yes
No
Please provide information below:
Passport Number:
Country/Authority that Issued Passport/Travel:
Reason:
U.S. Point of Contact Information
Contact Person First Name:
Contact Person Last Name:
Organization Name:
Relationship to You:
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Saint Martin
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Country
Family Information: Relatives
Father's Last Name:
Father's Date of Birth
*
Father's City, Country of Birth
*
Father's Current Address:
*
Is your father in the U.S.?
*
Select
Yes
No
Father's USA Status:
*
If Deceased, Please mention Date of Deceased:
Mother's First name:
*
Mother's Last Name:
Mother's Date of Birth
*
Mother's City, Country of Birth
*
Mother's Current Address:
*
Is your mother in the U.S.?
*
Select
Yes
No
Mother's USA Status:
*
If Deceased, Please mention Date of Deceased:
Do you have any immediate relatives, not including parents, in the United States?
*
Select
Yes
No
Provide Details:
First Name
Last Name
Relationship
Current Address
Do you have any other relatives in the United States?
*
Select
Yes
No
Provide Details:
First Name
Last Name
Relationship
Current Address
Personal Information About Spouse
Previous Spouse First name:
*
Previous Spouse Last name:
*
Date Of Marriage
*
Date Of Marriage Ended
*
Date Of Marriage
*
Spouse First name:
*
Spouse Last name:
Spouse's Country/Region of Origin (Nationality):
*
Spouse Date of Birth
*
Spouse City, Country of Birth
*
Spouse Current Address:
*
Spouse Phone Number
*
Current Work/Eduacation Experience of the Principal Applicant
Current Work/Education Experience of the Principal Applicant (if any)
Start Date (DD-MM-YYYY)
Name & Address of Employer/School
Job Title/Course of Study:
Montly Income
Briefly describe your duties:
Previous Work/Education Experience of the Principal Applicant
Were you previously employed?
*
Select
Yes
No
Previous Work Experience of the Principal Applicant (if any)
From (DD-MM-YYYY)
To (DD-MM-YYYY)
Name & Address of Employer
Job Title
Montly Income
Briefly describe your duties:
Have you attended any educational institutions at a secondary level or above?
*
Select
Yes
No
Previous Education Experience of the Principal Applicant (if any)
From (DD-MM-YYYY)
To (DD-MM-YYYY)
Name & Address of School
Course of Study:
Briefly describe your duties:
Do you belong to a clan or tribe?
*
Select
Yes
No
Please provide details:
Provide a List of Languages You Speak:
Security and Background Information
Have you traveled to any countries/regions within the last five years?
*
Select
Yes
No
Please provide details with Date and Reason
Have you belonged to, contributed to, or worked for any professional, social, or charitable organization?
*
Select
Yes
No
Please provide details:
Do you have any specialized skills or training, such as firearms, explosives, nuclear, biological, or chemical experience?
*
Select
Yes
No
Please provide details:
Have you ever served in the military?
*
Select
Yes
No
Please provide details:
Have you ever served in, been a member of, or been involved with a paramilitary unit, vigilante unit, rebel group, guerrilla group, or insurgent organization?
*
Select
Yes
No
Please provide details:
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.)
*
Select
No
Yes
Please provide details:
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?
*
Select
Yes
No
Please provide details:
Are you or have you ever been a drug abuser or addict?
*
Select
Yes
No
Please provide details:
Have you ever been arrested or convicted for any offense or crime, even though subject of a pardon, amnesty, or other similar action?
*
Select
Yes
No
Please provide details:
Have you ever violated, or engaged in a conspiracy to violate, any law relating to controlled substances?
*
Select
Yes
No
Please provide details:
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?
*
Select
Yes
No
Please provide details:
Have you ever been involved in, or do you seek to engage in, money laundering?
*
Select
Yes
No
Please provide details:
Have you ever committed or conspired to commit a human trafficking offense in the United States or outside the United States?
*
Select
Yes
No
Please Provide Details:
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?
*
Select
Yes
No
Please Provide Details:
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?
*
Select
Yes
No
Please Provide Details:
Have your spouse ever comDo you seek to engage in espionage, sabotage, export control violations, or any other illegal activity while in the United States? mitted, been arrested for, been charged with, or convicted of any criminal offence in any country?
*
Select
Yes
No
Please Provide Details:
Do you seek to engage in terrorist activities while in the United States or have you ever engaged in terrorist activities?
*
Select
Yes
No
Please Provide Details:
Have you ever or do you intend to provide financial assistance or other support to terrorists or terrorist organizations?
*
Select
No
Yes
Please Provide Details:
Are you a member or representative of a terrorist organization?
*
Select
Yes
No
Please Provide Details:
Are you the spouse, son, or daughter of an individual who has engaged in terrorist activity, including providing financial assistance or other support to terrorists or terrorist organizations, in the last five years?
*
Select
Yes
No
Please Provide Details:
Have you ever ordered, incited, committed, assisted, or otherwise participated in genocide?
*
Select
Yes
No
Please Provide Details:
Have you ever committed, ordered, incited, assisted, or otherwise participated in torture?
*
Select
Yes
No
Please Provide Details:
Have you committed, ordered, incited, assisted, or otherwise participated in extrajudicial killings, political killings, or other acts of violence?
*
Select
Yes
No
Please Provide Details:
Have you ever engaged in the recruitment or the use of child soldiers?
*
Select
Yes
No
Please Provide Details:
Have you, while serving as a government official, been responsible for or directly carried out, at any time, particularly severe violations of religious freedom?
*
Select
Yes
No
Please Provide Details:
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?
*
Select
Yes
No
Please Provide Details:
Have you ever been directly involved in the coercive transplantation of human organs or bodily tissue?
*
Select
Yes
No
Please Provide Details:
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?
*
Select
Yes
No
Please Provide Details:
Have you ever been removed or deported from any country?
*
Select
Yes
No
Please Provide Details:
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?
*
Select
Yes
No
Please Provide Details:
Have you voted in the United States in violation of any law or regulation?
*
Select
Yes
No
Please Provide Details:
Have you ever renounced United States citizenship for the purposes of avoiding taxation?
*
Select
Yes
No
Please Provide Details:
Verify All the details before Submission