30. Have You Ever Been Issued a U.S. Visa?
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Privacy Act and Paperwork Reduction Act Statements
INA Section 222(f) provides that visa issuance and refusal records shall be considered confidential and shall be used only for the formulation, amendment,
administration, or enforcement of the immigration, nationality, and other laws of the United States. Certified copies of visa records may be made available to a court
which certifies that the information contained in such records is needed in a case pending before the court.
Public reporting burden for this collection of information is estimated to average 1 hour per response, including time required for searching existing data sources,
gathering the necessary data, providing the information required, and reviewing the final collection. You do not have to provide the information unless this collection
displays a currently valid OMB number. Send comments on the accuracy of this estimate of the burden and recommendations for reducing it to: U.S. Department of
State, A/RPS/DIR, Washington, DC 20520.
While a YES answer does not automatically signify ineligibility for a visa, if you answered YES you may be required to personally appear before a
consular officer.
41. I certify that I have read and understood all the questions set forth in this application and the answers I have furnished on this form are true and
correct to the best of my knowledge and belief. I understand that any false or misleading statement may result in the permanent refusal of a visa
or denial of entry into the United States. I understand that possession of a visa does not automatically entitle the bearer to enter the United States
of America upon arrival at a port of entry if he or she is found inadmissible.
40. Application Prepared By:
DATE (dd-mmm-yyyy)
39. Was this Application Prepared by Another Person on Your Behalf?
(If answer is YES, then have that person complete item 40.)
Signature of Person Preparing Form:
Yes
No
NAME:
APPLICANT'S SIGNATURE
DATE (dd-mmm-yyyy)
31. Have You Ever Been Refused a U.S. Visa?
WHAT TYPE OF VISA?
WHERE?
WHEN?
34. Names and Relationships of Persons Traveling With You
38. IMPORTANT: ALL APPLICANTS MUST READ AND CHECK THE APPROPRIATE BOX FOR EACH ITEM.
A visa may not be issued to persons who are within specific categories defined by law as inadmissible to the United States (except when a waiver
is obtained in advance). Is any of the following applicable to you?
Have you ever been arrested or convicted for any offense or crime, even though subject of a pardon, amnesty or other
similar legal action? Have you ever unlawfully distributed or sold a controlled substance (drug), or been a prostitute or
procurer for prostitutes?
Have you ever been refused admission to the U.S., or been the subject of a deportation hearing, or sought to obtain or
assist others to obtain a visa, entry into the U.S., or any other U.S. immigration benefit by fraud or willful
misrepresentation or other unlawful means? Have you attended a U.S. public elementary school on student (F) status or
a public secondary school after November 30, 1996 without reimbursing the school?
Do you seek to enter the United States to engage in export control violations, subversive or terrorist activities, or any
other unlawful purpose? Are you a member or representative of a terrorist organization as currently designated by the
U.S. Secretary of State? Have you ever participated in persecutions directed by the Nazi government of Germany; or
have you ever participated in genocide?
Have you ever violated the terms of a U.S. visa, or been unlawfully present in, or deported from, the United States?
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, voted in the United States in violation of any law or regulation, or renounced U.S. citizenship for the
purpose of avoiding taxation?
Have you ever been afflicted with a communicable disease of public health significance or a dangerous physical or mental
disorder, or ever been a drug abuser or addict?
32. Do You Intend To Work in The U.S.?
(If YES, give the name and complete address of U.S. employer.)
33. Do You Intend To Study in The U.S.?
(If YES, give the name and complete address of the school.)
Has Your U.S. Visa Ever Been Cancelled or Revoked?
36. Has Anyone Ever Filed an Immigrant Visa Petition on Your Behalf?
If Yes, Who?
37. Are Any of The Following Persons in The U.S., or Do They Have U.S. Legal Permanent Residence or U.S. Citizenship?
Mark YES or NO and indicate that person's status in the U.S. (i.e., U.S. legal permanent resident, U.S. citizen, visiting, studying, working, etc.).
YES NO
Husband/
Wife
YES NO
Father/
Mother
YES NO
Fiance/
Fiancee
YES NO
Son/
Daughter
Brother/
Sister
YES NO
NoYes
NoYes
NoYes
WHAT TYPE OF VISA?
WHERE?
WHEN?
Yes No
35.
Yes
No
Relationship to Applicant:
ADDRESS:
Yes
No
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
