Name of Applicant (Last, First, MI)
Full Name Relationship Date (mm-dd-yyyy) and Place of Birth
U.S. Department of State
CLASS A NONIMMIGRANT VISA REFERRAL
DS-4034
03-2004
TO: Chief of Consular Section
Date (mm-dd-yyyy)
SUBJECT: Visa Referral
Date (mm-dd-yyyy) and Place of Birth
ACCOMPANYING RELATIVE(s) - Additional relatives should be listed on back of form
I recommend visa issuance for the visa applicant named above who is well and favorably known to me. The
following documents are attached:
Position of applicant/Nature of contact:
Issuing a visa to the applicant is in the U.S. national interest because: (continue on back if necessary)
Purpose of applicant's travel:
Destination of applicant's travel: Date of travel (mm-dd-yyyy):
I certify that the referred applicant is personally known to me and, to the best of my knowledge, meets all criteria for A referral status and
presents no threat to the national security or safety of the United States.
Name of Referring Officer Title
Signature Date (mm-dd-yyyy)
Signature Date (mm-dd-yyyy)
Name of Chief of Mission, Deputy Chief of Mission, or Principal Officer
Title
(Optional/as applicable) I certify that a CLASS Check and security review of the referred applicant have been done, and I recommend that
the applicant be exempt from the following:
NSEERS requirements
Visas condor requirements
US-VISIT requirements
Passport Completed Form DS-156 Completed Form DS-157 and/or DS-158 (If applicable)
Photo Supporting Documents MRV Fee Receipt
I certify that to the best of my knowledge, the referred applicant meets all criteria for A referral status and presents no threat to the national
security or safety of the United States.
Name of Approving Officer Title
Signature Date (mm-dd-yyyy)
