DS160

PERSONAL
PERSONAL INFORMATION
Name Provided: (PASSPORTNAME)
Full Name in Native Alphabet: -NONE-
Other Names sed:
Other Name (!):
Tele"ode Name sed:
Se#:
Marital Status:
$ate o% &irth:
Pla"e o% &irth:
Nationalit':
Other Nationalities:
(S( National )denti%i"ation Number: P*S ANS+ER T,ESE ($OES NOT APP*- )F NONE)
(S( So"ial Se"urit' Number:
(S( Ta#pa'er )$ Number:
Address and Phone Information
,ome Address:
.it':
State/Provin"e:
Postal 0one/0)P .ode:
.ountr':
Same Mailin1 Address2
Primar' Phone Number:
Se"ondar' Phone Number:
+or3 Phone Number:
Email Address:
Passport/Trae! Do"#ment Information
Passport/Travel $o"ument T'pe:
Passport/Travel $o"ument Number:
Passport &oo3 Number:
.ountr'/Authorit' that )ssued
Passport/Travel $o"ument:
.it' 4here issued:
.ountr' 4here issued:
)ssuan"e $ate:
E#piration $ate:
,ave 'ou ever lost a passport or
had one stolen2
P*S ANS+ER T,)S
TRA$EL
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TRA$EL INFORMATION
Purpose o% Trip to the (S( (!):
Spe"i%':
)ntended $ate o% Arrival:
)ntended *en1th o% Sta' in (S(:
Address 4here 'ou 4ill sta' in the (S(:
Person/Entit' Pa'in1 %or -our Trip:
TRA$EL %OMPANION INFORMATION
Other Persons Travelin1 4ith -ou:
Are 'ou travelin1 as part o% a 1roup or or1ani5ation2
Persons Travelin1 4ith -ou:
Name (!):
Relationship to -ou:
Name (6):
Relationship to -ou:
Name (7):
Relationship to -ou:
PRE$IO&S &S TRA$EL INFORMATION
,ave 'ou ever been in the (S(2
!( $ate o% last arrival in the S (month-da'-'ear)
6( *en1th o% sta' in the S (in da's or 4ee3s or 'ears)
,ave 'ou ever been issued a (S( visa2
!( )ssue date o% 'our last S 8)SA (month-da'-'ear)
6( T'pe o% visa 4as issued
7( S 8)SA Number (lo4er ri1ht hand "orner9 in red
letters)
,ave 'ou been ten-%in1er printed2
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,ave 'ou ever been :
!( re%used a (S( 8isa
6( re%used admission to the nited States
7( 4ithdra4n 'our appli"ation %or admission at the port
o% entr'2
+hen 4ere 'ou re%used a S visa/admission/ 4ithdra4al o%
admission to the S2 (month-'ear)
+hat is the reason %or re%usal o% visa/admission/4ithdra4al o%
admission to the S2
,as an'one ever %iled an immi1rant petition on 'our behal%
4ith the nited States .iti5enship and )mmi1ration Servi"es2
&(S( %ONTA%T INFORMATION
.onta"t Person Name in the (S(:
Or1ani5ation Name in the (S(:
Relationship to -ou:
(S( .onta"t Address:

Phone Number:
Email Address:
Edit Fami!) Information* Re!aties
Father;s Surnames:
Father;s <iven Names:
Father;s $ate o% &irth:
)s 'our %ather in the (S(2
Mother;s Surnames:
Mother;s <iven Names:
Mother;s $ate o% &irth:
)s 'our mother in the (S(2
$o 'ou have an' immediate
relatives9 not in"ludin1 parents in
the (S(2 ("hildren or spouse)
$o 'ou have an' other relatives in
the nited States2
Edit Fami!) Information* Spo#se
Spouse;s Full Name:
Page + of 6
Spouse;s $ate o% &irth:
Spouse;s Nationalit':
Spouse;s .it' o% &irth:
Spouse;s .ountr' o% &irth:
Spouse=s Address:
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WORK/EDUCATION
Primar' O""upation:
Present Emplo'er or S"hool
Name:
Present Emplo'er or S"hool
Address:
.it':
State/Provin"e:
Postal 0one/0ip .ode:
.ountr':
+or3 Phone Number:
Monthl' Salar' in *o"al
.urren"' (i% emplo'ed):
&rie%l' $es"ribe 'our $uties:
SECURITY
Edit Part 1
$o 'ou have a "ommuni"able disease o% publi" health si1ni%i"an"e2 (.ommuni"able diseases o% publi"
si1ni%i"an"e in"lude "han"roid9 1onorrhea9 1ranuloma in1uinale9 in%e"tious lepros'9 l'mpho1ranuloma
venereum9 in%e"tious sta1e s'philis9 a"tive tuber"ulosis9 and others diseases as determined b' the
$epartment o% ,ealth and ,uman Servi"es()
$o 'ou have a mental or ph'si"al disorder that poses or is li3el' to pose a threat to the sa%et' or
4el%are o% 'oursel% or others2
Are 'ou or have 'ou ever been a dru1 abuser or addi"t2
Edit Part 2
,ave 'ou ever been arrested or "onvi"ted %or an' o%%ense or "rime9 even thou1h sub>e"t o% a pardon9
amnest'9 or other similar a"tion2
,ave 'ou ever violated9 or en1a1ed in a "onspira"' to violate9 an' la4 relatin1 to "ontrolled
substan"es2
Are 'ou "omin1 to the nited States to en1a1e in prostitution or unla4%ul "ommer"iali5ed vi"e or have
'ou been en1a1ed in prostitution or pro"urin1 prostitutes 4ithin the past !? 'ears2
,ave 'ou ever been involved in9 or do 'ou see3 to en1a1e in9 mone' launderin12
,ave 'ou ever "ommitted or "onspired to "ommit a human tra%%i"3in1 o%%ense in the nited States or
outside the nited States2
Are 'ou the spouse9 son9 or dau1hter o% an individual 4ho has "ommitted or "onspired to "ommit a
human tra%%i"3in1 o%%ense in the nited States or outside the nited States and have 'ou 4ithin the
last %ive 'ears9 3no4in1l' bene%ited %rom the tra%%i"3in1 a"tivities2
,ave 'ou 3no4in1l' aided9 abetted9 assisted or "olluded 4ith an individual 4ho has "ommitted or
"onspired to "ommit a severe human tra%%i"3in1 o%%ense in the nited States or outside the nited
States2
Edit Part 3
$o 'ou see3 to en1a1e in espiona1e9 sabota1e9 e#port "ontrol violations9 or an' other ille1al a"tivit'
4hile in the nited States2
$o 'ou see3 to en1a1e in terrorist a"tivities 4hile in the nited States or have 'ou ever en1a1ed in
terrorist a"tivities2
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,ave 'ou ever or do 'ou intend to provide %inan"ial assistan"e or other support to terrorists or terrorist
or1ani5ations2
Are 'ou a member or representative o% a terrorist or1ani5ation2
,ave 'ou ever ordered9 in"ited9 "ommitted9 assisted9 or other4ise parti"ipated in 1eno"ide2
,ave 'ou ever "ommitted9 ordered9 in"ited9 assisted9 or other4ise parti"ipated in torture2
,ave 'ou "ommitted9 ordered9 in"ited9 assisted9 or other4ise parti"ipated in e#tra>udi"ial 3illin1s9
politi"al 3illin1s9 or other a"ts o% violen"e2
,ave 'ou ever en1a1ed in the re"ruitment or the use o% the "hild soldiers2
,ave 'ou9 4hile servin1 as a 1overnment o%%i"ial9 been responsible %or or dire"tl' "arried out9 at an'
time9 parti"ularl' severe violations o% reli1ious %reedom2
,ave 'ou ever been dire"tl' involved in the establishment or en%or"ement o% the population "ontrols
%or"in1 a 4oman to under1o an abortion a1ainst her %ree "hoi"e or a man or a 4oman to under1o
sterili5ation a1ainst his or her %ree 4ill2
,ave 'ou ever been dire"tl' involved in the "oer"ive transplantation o% human or1ans or bodil' tissue2
Edit Part 4
,ave 'ou ever sou1ht to obtain or assist others to obtain a visa9 entr' into the nited States9 or an'
other nited States immi1ration bene%it b' %raud or 4ill%ul misrepresentation or other unla4%ul means2

Edit Part 5
,ave 'ou ever 4ithheld "ustod' o% a (S( "iti5en "hild outside the nited States %rom a person 1ranted
le1al "ustod' b' a (S( "ourt2

,ave 'ou voted in the nited States in violation o% an' la4 or re1ulation2
,ave 'ou ever renoun"ed nited States "iti5enship %or the purpose o% avoidin1 ta#ation2
-END HERE-
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