DS 160 Questionare – USA

* If divorced/seperated/diceased please answer below

Province Marriage ended

Reason Marriage ended

Country/Region of Origin (Nationality)

Do you hold or have you held any nationality other than the one indicated above or nationality?

Are you a permanent resident of a country/region other than your country/region of origin (nationality) above?

National Identification Number

U.S. Social Security Number

U.S. Taxpayer ID Number

* Is your mailing address the same? If not please complete Postal details

Primary Phone Number

Secondary Phone Number

Do you have any additional phone numbers?

Do you have any additional email addresses? (please list all other email address you use/used)

Do you have a Social Media Account i.e. Facebook/Instagram/Twitter? If Yes, please list below:

Do you have any additional social media presence?

Passport/Travel Document Type:

Passport/Travel Document Number:

Passport Book Number:

Country/Authority that Issued Passport/Travel Document

State/Province Where Issued

Have you ever lost a passport or had one stolen?

Purpose of Trip to the USA (visa type)

Intended Date of Arrival

Intended Length of Stay in the US

Address where you will stay in the US

Person/Entity Paying for your Trip

Are there other persons traveling with you

Yes No

If "yes" please list:
Full name, Surname, Relationship to you

Have you ever been in the U.S.

Yes No

Have you ever been issued a U.S. visa. If "Yes" please complete

Yes No

Date last Visa was issued

Visa Number (Red number on your visa)

Do you or did you hold a us Driver's License? If "Yes" please complete

Yes No

Drivers License number

Are you applying for the same visa?

Are you applying in the same country

Has your Visa ever been lost of stolen?

Has your Visa ever been cancelled or revoked

Have you ever been refused a US Visa

Have you ever been refused a U.S. visa, or been refused admission to the United States, or withdrawn your application for admission at the port of entry

Has anyone ever filed an immigration petition on your behalf with the United States Citizenship and Immigration Services

U.S. CONTACT INFORMATION

Contact Person Name in the U.S. (if applicable)

Organization in the U.S (if applicable)

Relationship to You (if applicable)

U.S. Contact Address:

Father's Given Names

Father's Date of Birth

Is your father in the US?

Yes No

Mother's Given Names

Mother's Date of Birth

Is your mother in the US?

Yes No

Do you have any immediate relatives in the US

Spouse Name and Surname

Country/Region of Origin (Nationality)

Spouse Address same as home address

WORK / EDUCATION / TRAINING INFO (from 2019 to recent)

Present Employer Name or School Name

Primanry Occupation (example Business/Accounting/Medical)

Present Employer Name or School Name

Current Monthly Salary

Briefly describe duties

Start Date of Employment

Previous Employment (1) (example Business/Accounting/Medical)

Employer Name or School Name

Supervisor Name and Surname:

Briefly describe duties

Previous Employment (2) (example Business/Accounting/Medical)

Employer Name or School Name

Supervisor Name and Surname:

Briefly describe duties

Previous Employment (3) (example Business/Accounting/Medical)

Employer Name or School Name

Supervisor Name and Surname:

Briefly describe duties

EDUCATIONAL INSTITUTION

Address of Institution

Date of Attendance from

Date of Attendance to

SECURITY AND BACKGROUND INFO

Do you belong to a tribe of clan?

List the languages you speak?

Have you travelled to any other countries in the past 5 years?

Yes No

If yes, please list all the countries for the past 5 years?

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 others diseases as determined by the Department of Health and Human Services.)

Yes No

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 No

Are you or have you ever been a drug abuser or addict?

Yes No

Have you ever been arrested or convicted for any offense or crime, even though subject of a pardon, amnesty, or other similar action?

Yes No

Have you ever violated, or engaged in a conspiracy to violate, any law relating to controlled substances?

Yes No

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 No

Have you ever been involved in, or do you seek to engage in, money laundering?

Yes No

Have you ever committed or conspired to commit a human trafficking offense in the United States or outside the United States?

Yes No

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 No

Have you 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 No

Do you seek to engage in espionage, sabotage, export control violations, or any other illegal activity while in the United States?

Yes No

Do you seek to engage in terrorist activities while in the United States or have you ever engaged in terrorist activities?

Yes No

Have you ever or do you intend to provide financial assistance or other support to terrorists or terrorist organizations?

Yes No

Are you a member or representative of a terrorist organization?

Yes No

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?

Yes No

Have you ever ordered, incited, committed, assisted, or otherwise participated in genocide?

Yes No

Have you ever committed, ordered, incited, assisted, or otherwise participated in torture?

Yes No

Have you committed, ordered, incited, assisted, or otherwise participated in extrajudicial killings, political killings, or other acts of violence?

Yes No

Have you ever engaged in the recruitment or the use of the child soldiers?

Yes No

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 No

Have you ever been directly involved in the establishment or enforcement of the 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 No

Have you ever been directly involved in the coercive transplantation of human organs or bodily tissue?

Yes No

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 No

Have you ever been removed or deported from any country?

Yes No

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 No

Have you voted in the United States in violation of any law or regulation?

Yes No

Have you ever renounced United States citizenship for the purpose of avoiding taxation?

Yes No

DS 160 QUESTIONAIRE

CONSULATE YOU WISH TO APPLY

PERSONAL ADDRESS, PHONE, AND PASSPORT INFO:

TRAVEL INFORMATION

U.S. CONTACT INFORMATION

FAMILY INFORMATION

WORK / EDUCATION / TRAINING INFO (from 2019 to recent)

Present Employer Name or School Name

Previous Employment (1) (example Business/Accounting/Medical)

Previous Employment (2) (example Business/Accounting/Medical)

Previous Employment (3) (example Business/Accounting/Medical)

EDUCATIONAL INSTITUTION

SECURITY AND BACKGROUND INFO

CONTACT US