Applicant Information
Passport Information
Contact Information
Trip Details
U.S. Contact
Family Background
Employment / Education
Security Questions
Review & Certification

Applicant Information

Please make sure the first name(s) are exactly as shown on your passport or travel document.

Please make sure the family name(s) are exactly as shown on your passport or travel document.

COMPLETE NAME IN NATIVE LANGUAGE - Does not apply

Telecode is 4 digit code number that represents characters in some non-Roman alphabet names.

Please add your marital status that is recognized under the laws of the country.

Please add in your date of birth, as listed in your travel documents or ID.

Please add the name of the city/town/village where you were born.

REGION/STATE/PROVINCE OF BIRTH - Does not apply

Please choose the country you were born in, as per your travel documents.

Passport Information

Enter the passport number exactly as it appears on the passport information page. Most Passport number are 8 to 11 characters long.

PASSPORT BOOK NUMBER - Does not apply

Please add the city where your passport was issued.

Please add the region/state/province where your passport was issued.

Please add the country/region where your passport was issued.

PASSPORT EXPIRATION DATE - Does not apply
PASSPORT/TRAVEL DOCUMENT NUMBER - Does not apply

Please select the country which issued your Passport.

PASSPORT/TRAVEL DOCUMENT NUMBER - Does not apply

Please select the country which issued your Passport.

PASSPORT/TRAVEL DOCUMENT NUMBER - Does no apply

Please select the country which issued your Passport.

Please select the country of citizenship, as displayed on your passport.

Additional Nationalities

Please add the national ID number that your government provides.

NATIONAL IDENTIFICATION NUMBER - Does not apply

(Social Security Number). Please identify and fill in the U.S Social Security area number.

U.S. SOCIAL SECURITY AREA NUMBER - Does not apply

Please identify and fill in the U.S Social Security group number.

U.S. SOCIAL SECURITY GROUP NUMBER - Does not apply

Please identify and fill in the U.S Social Security serial number.

U.S. SOCIAL SECURITY SERIAL NUMBER - Does not apply

Please identify and fill in the U.S Taxpayer ID Number.

U.S. U.S. TAXPAYER ID NUMBER - Does not apply

Contact Information

Please add in the field the street and the number.

Please add in the field the floor number and/or building number.

PROVINCE/STATE/REGION - Does not apply
ZIP CODE NUMBER - Does not apply

Please add in the field the street and the number.

Please add in the field the floor number and/or building number.

Please add in the field the floor number and/or building number.

PROVINCE/STATE/REGION - Does not apply
ZIP CODE NUMBER - Does not apply

Please add the country/region where your passport was issued.

Please provide at least one phone number.

Travel Information

Please make sure to write the city of the application Country for the United States Visa.

PROVINCE/STATE/REGION - Does not apply
ZIP CODE NUMBER - Does not apply
PROVINCE/STATE/REGION - Does not apply
ZIP CODE NUMBER - Does not apply
Additional Contact #1
PROVINCE/STATE/REGION - Does not apply
ZIP CODE NUMBER - Does not apply
TELEPHONE NUMBER - Does not apply
EMAIL ADDRESS - Does not apply
Additional Contact #2
PROVINCE/STATE/REGION - Does no apply
ZIP CODE NUMBER - Does no apply
TELEPHONE NUMBER - Does no apply
EMAIL ADDRESS - Does no apply
Additional Contact #3
PROVINCE/STATE/REGION - Does no apply
ZIP CODE NUMBER - Does no apply
TELEPHONE NUMBER - Does no apply
EMAIL ADDRESS - Does no apply
Additional Contact #4
PROVINCE/STATE/REGION - Does not apply
ZIP CODE NUMBER - Does not apply
TELEPHONE NUMBER - Does not apply
EMAIL ADDRESS - Does not apply
Additional Contact #5
PROVINCE/STATE/REGION - Does not apply
ZIP CODE NUMBER - Does not apply
TELEPHONE NUMBER - Does not apply
EMAIL ADDRESS - Does not apply

Please add an approximate date of your travel plans to the Unites States.

Days in the United States Length of Stay in U.S. (numeric value)

INTENDED LENGTH OF STAY IN U.S. - Less than 24 hours
VISA NUMBER - Does not apply

Please provide some more details in relation to you being refused a U.S. Visa.

Person 1
Person 2
Person 3

Please think at the date you arrived in the U.S. If you can’t remember, please add your best estimate.

EMAIL ADDRESS - Does not apply
PROVINCE/STATE/REGION - Does not apply
ZIP CODE NUMBER - Does not apply
PROVINCE/STATE/REGION - Does not apply
ZIP CODE NUMBER - Does not apply

Contact Information in the United States

CONTACT PERSON - Does not apply

ORGANIZATION NAME - Does not apply
EMAIL ADDRESS - Does not apply

Family Background

WHAT IS YOUR FATHER'S NAME? - Does not apply
WHAT IS YOUR MOTHER'S NAME? - Does not apply
CITY OF SPOUSE'S BIRTH - Does not apply
STATE/PROVINCE - Does not apply
POSTAL ZONE/ZIP CODE - Does not apply
CITY OF SPOUSE'S BIRTH - Does not apply
1. Spouse Information
FORMER SPOUSE'S CITY OF BIRTH - Does not apply

Please think at the date you started marriage. If you can’t remember, try to add in your best estimate.

Please think at the date you ended marriage. If you can’t remember, try to add in your best estimate.

2. Spouse Information
FORMER SPOUSE'S CITY OF BIRTH - Does not apply

Please think at the date you started marriage. If you can’t remember, try to add in your best estimate.

Please think at the date you ended marriage. If you can’t remember, try to add in your best estimate.

3. Spouse Information
FORMER SPOUSE'S CITY OF BIRTH - Does not apply

Please think at the date you started marriage. If you can’t remember, try to add in your best estimate.

Please think at the date you ended marriage. If you can’t remember, try to add in your best estimate.

4. Spouse Information
FORMER SPOUSE'S CITY OF BIRTH - Does not apply

Please think at the date you started marriage. If you can’t remember, try to add in your best estimate.

Please think at the date you ended marriage. If you can’t remember, try to add in your best estimate.

5. Spouse Information
FORMER SPOUSE'S CITY OF BIRTH - Does not apply

Please think at the date you started marriage. If you can’t remember, try to add in your best estimate.

Please think at the date you ended marriage. If you can’t remember, try to add in your best estimate.

Employment / Education

PROVINCE/STATE/REGION - Does not apply
ZIP CODE NUMBER - Does not apply
Please add the started date of your current job.

Please think at your current monthly income and insert a value as closest to reality as possible.

MONTHLY INCOME - Does not apply
You can provide any type of description of day tasks and responsibilities.
Previous job #1
PROVINCE/STATE/REGION - Does not apply
ZIP CODE NUMBER - Does not apply