Country/Region of Origin (Nationality)

Do you hold any other nationality?

Yes No

Other Country/Region of Nationality Passport Number of Other Nationality

Are you a permanent resident of another country?

Yes No

Country/Region of Permanent Residence

National Identification Number U.S. Social Security Number U.S. Taxpayer ID Number

Purpose of Trip to the U.S. - SELECT ONE - ACADEMIC OR LANGUAGE STUDENT (F) BUSINESS/TOURISM (B) WORKER (H) Specify - SELECT - STUDENT (F1) BUSINESS & TOURISM (B1/B2)

Have you made specific travel plans?

Yes No

Intended Date of Departure

Day Month MM JANFEBMARAPR MAYJUNJULAUG SEPOCTNOVDEC Year

Flight Number/Carrier City Where You Boarded City of Final Destination

Intended Date of Arrival

Day Month MM JANFEBMARAPR MAYJUNJULAUG SEPOCTNOVDEC Year

Intended Length of Stay in U.S. (Years)

Address Where You Will Stay in the U.S.

Street Address (Line 1) Street Address (Line 2) City State ZIP Code Person/Entity Paying for Your Trip SELF OTHER PERSON COMPANY/ORGANIZATION

Are there other persons traveling with you?

Yes No

Surname Given Names Relationship to You - SELECT ONE - SPOUSE CHILD PARENT SIBLING FRIEND COLLEAGUE OTHER RELATIVE OTHER

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Add Another Companion

Home Address

Street Address (Line 1) Street Address (Line 2) City State/Province Postal Zone/ZIP Code Country/Region

Is Mailing Address same as Home?

Yes No

Mailing Address

Street Address (Line 1) Street Address (Line 2) City State/Province Postal Zone/ZIP Code Country/Region

Phone

Primary Phone Number Secondary Phone Number Work Phone Number

Have you used other phone numbers in the last five years?

Yes No

Previous Phone Number

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Add Another Phone

Email

Email Address

Have you used other email addresses in the last five years?

Yes No

Previous Email Address

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Add Another Email

Social Media

Other content-sharing websites used within last five years?

Yes No

Website Name/URL

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Add Another Website

Passport/Travel Document TypeREGULAROFFICIALDIPLOMATIC Passport/Travel Document Number Passport Book Number Country/Authority that Issued

Where was the Passport/Travel Document Issued?

City State/Province Country/Region

Issuance Date

DayMonthJANFEBMARAPRMAYJUNJULAUGSEPOCTNOVDECYear

Expiration Date

DayMonthJANFEBMARAPRMAYJUNJULAUGSEPOCTNOVDECYear

Have you ever lost a passport or had one stolen?

Yes No

Surnames Given Names Organization Name Relationship to YouSCHOOL OFFICIALFRIENDRELATIVEOTHER

Address and Phone of Point of Contact

U.S. Street Address (Line 1) U.S. Street Address (Line 2) City State ZIP Code Phone Number Email Address

Father

Surnames Given Names

Father's Date of Birth

DayMonthJANFEBMARAPRMAYJUNJULAUGSEPOCTNOVDECYear

Is your father in the U.S.?

Yes No

Mother

Surnames Given Names

Mother's Date of Birth

DayMonthJANFEBMARAPRMAYJUNJULAUGSEPOCTNOVDECYear

Is your mother in the U.S.?

Yes No

Immediate relatives in the U.S.?

Yes No

Any other relatives in the U.S.?

Yes No

Primary Occupation- SELECT ONE -EDUCATIONENGINEERINGBUSINESSSTUDENTOTHER Present Employer or School Name

Address

Street Address (Line 1) Street Address (Line 2) City State/Province Postal Zone/ZIP Code Country/Region

Start Date

DayMonthJANFEBMARAPRMAYJUNJULAUGSEPOCTNOVDECYear

Work Phone Number Monthly Income in Local Currency Briefly describe your duties

Were you previously employed?

Yes No

Have you attended educational institutions at a secondary level or above?

Yes No

Do you belong to a clan or tribe?

Yes No

Languages You Speak

Traveled to any countries/regions in last five years?

Yes No

Belonged to or worked for any organizations?

Yes No

Any specialized skills or training (firearms, explosives, nuclear, biological, or chemical)?

Yes No

Have you ever served in the military?

Yes No

Paramilitary/vigilante/rebel/insurgent involvement?

Yes No

Communicable disease of public health significance?

Yes No

Mental or physical disorder that poses or is likely to pose a threat to safety?

Yes No

If yes, explain

Drug abuser or addict?

Yes No

Arrested or convicted for any offense or crime?

Yes No

Violated or engaged in conspiracy to violate any law relating to controlled substances?

Yes No

Prostitution or unlawful commercialized vice in the past 10 years?

Yes No

Money laundering involvement?

Yes No

Illegal activity in U.S. (espionage, sabotage, export control violations, etc.)?

Yes No

Terrorist activities or support?

Yes No

Financial assistance or support to terrorists or terrorist organizations?

Yes No

Member or representative of a terrorist organization?

Yes No

Sought to obtain or assist others to obtain a visa/entry by fraud or misrepresentation?

Yes No

Removed or deported from any country?

Yes No

Withheld custody of a U.S. citizen child outside the U.S. from a person granted legal custody by a U.S. court?

Yes No

Voted in the United States in violation of any law or regulation?

Yes No

Renounced U.S. citizenship for the purpose of avoiding taxation?

Yes No

SEVIS ID Name of School Course of Study Street Address (Line 1) Street Address (Line 2) City State Postal Zone/ZIP Code

Current Location