(base or city/province)
Dates of Employment
(mm-dd-yyyy) or "Present"
Job Title Supervisor's Name
Company or Employer
19. List your last five employers, including your current employer.
17. List all countries that have ever issued you a passport.16. List all countries you have entered in the last ten years.
(Give the year of each visit)
18. Have you ever lost a
passport or had one stolen?
PLEASE TYPE OR PRINT YOUR ANSWERS IN THE SPACE PROVIDED BELOW EACH ITEM
PLEASE ATTACH AN ADDITIONAL SHEET IF YOU NEED MORE SPACE TO CONTINUE YOUR ANSWERS
1. Last Name(s) (List all spellings) 2. First Name(s) (List all spellings) 3. Full Name (In native alphabet)
20. Have you ever applied for Chief of Mission Approval?
If YES, please provide the case number(s) of the application(s).
4. Clan or Tribe Name (If applicable) 5. All other names/aliases (If applicable)
6. Date of Birth (mm-dd-yyyy) 7. Place of Birth (City, State/Province, Country)
Confidentiality Statement - 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.
Paperwork Reduction Act Statement - 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/GIS/DIR, Washington, DC 20520.
CONFIDENTIALITY AND PAPERWORK REDUCTION ACT STATEMENTS
SUPPLEMENTAL SIV CHIEF OF MISSION APPLICATION
Approved OMB 1405-0134
Estimated Burden 1 Hour*
U.S. Department of State
8. Passport Number 9. National Identity Number (Tazkera)
10. Sex 11. Spouse's Full Name (If married)
12. Father's Full Name 13. Mother's Full Name
14. Email Address and Phone Number
15. List names and dates of birth for your children (currently under age 21)
(If no longer employed)
I understand all the information I have provided in, or in support of, this application may be provided to other U.S. government agencies authorized to use such information for purposes
including enforcement of the laws of the United States. I understand all of the information contained in this form and I certify under penalty of perjury under the laws of the United States
of America that the foregoing is complete, true, and correct. I understand that any willfully false or misleading statement or willful concealment of a material fact made by me herein may
result in refusal of the visa, denial of admission to the United States, and, may subject me to criminal prosecution and/or removal from the United States.
Applicant's Signature Date (mm-dd-yyyy)
click to sign
click to edit