USA Visa Form
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Email *
Have you ever used other names (i.e., maiden, religious, professional, alias, etc.)? 
 *
Marital Status
 *
Required
Personal Information 2
Country/Region of Origin (Nationality) 
 *
Do you hold or have you held any nationality other than the one indicated above on nationality? 
 *
Are you a permanent resident of a country/region other than your country/region of origin (nationality)
indicated above?
 *
National Identification Number
 *
Purpose of Trip to the U.S.
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Specify
 *
Have you made specific travel plans? 
 *
Intended Date of Arrival 
 *
MM
/
DD
/
YYYY
Intended Length of Stay in U.S.
 *
Help: Arrival Plans

If you are unsure of your travel plans, please provide an
estimate.
Address Where You Will Stay in the U.S.
Street Address (Line 1) 
City
 *
State 
 *
ZIP Code (if known) 
Person/Entity Paying for Your Trip 
 *
Required
Provide the following information: 
Surnames of Person Paying for Trip
Given Names of Person Paying for Trip
Telephone Number
Email Address 
Relationship to You
Is the address of the party paying for your trip the same as your Home or Mailing Address? 
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Travel Companions Information
Are there other persons traveling with you?
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Are you traveling as part of a group or organization?
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Surnames of Person Traveling With You
Given Names of Person Traveling With You
Relationship with Person 
Second Person Travelling with you
Surnames of Person Traveling With You 
Given Names of Person Traveling With You 
Relationship with Person 
Have you ever been in the U.S.? 
 *
Have you ever been issued a U.S. Visa? 
 *
Have you ever been refused a U.S. Visa, or been refused
admission to the United States, or withdrawn your
application for admission at the port of entry?
 *
Explain 
Has anyone ever filed an immigrant petition on your behalf
with the United States Citizenship and Immigration
Services?
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Provide information on your last five U.S. visits: 
Date Arrived 
MM
/
DD
/
YYYY
Length of Stay
Do you or did you ever hold a U.S. Driver’s License? 
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Help: Previous U.S. Visits 

If you are unsure about when you visited the U.S., please provide a best estimate.
Previous U.S. Visas 
Date Last Visa Was Issued
MM
/
DD
/
YYYY
Visa Number
Are you applying for the same type of visa? 
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Are you applying in the same country or location where the visa above was issued, and is this country or
location your place of principal of residence?
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Have you been ten-printed?
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Has your U.S. Visa ever been lost or stolen? 
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Has your U.S. Visa ever been cancelled or revoked? 
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Address and Phone Information
Street Address (Line 1) 
City
State/Province 
Postal Zone/ZIP Code
Country/Region 
Mailing Address 
Is your Mailing Address the same as your Home Address? 
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Phone 
Primary Phone Number
Secondary Phone Number
Work Phone Number
Have you used any other phone numbers in the last five years? 
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Email Address 
Have you used any other email addresses in the last five years? 
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Social Media Provider/Platform 
Social Media Identifier
Do you wish to provide information about your presence on any other websites or applications you have
used within the last five years to create or share content (photos, videos, status updates, etc.)? 
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U.S. Point of Contact Information 
Contact Person or Organization in the United States 
Contact Person 
Surnames
Given Names
Organization Name
Relationship to You 
U.S. Street Address (Line 1) 
City 
State
ZIP Code (if known) 
Phone Number
Email Address 
Family Information: Relatives
NOTE: Please provide the following information concerning your biological parents. If you are adopted,
please provide the following information on your adoptive parents.
Father's Full Name and Date of Birth
Surnames
Given Names 
Date of Birth 
MM
/
DD
/
YYYY
Is your father in the U.S.? 
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Mother's Full Name and Date of Birth 
Surnames 
Given Names
Date of Birth
MM
/
DD
/
YYYY
Is your mother in the U.S.? 
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Do you have any immediate relatives, not including parents, in the United States?
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Do you have any immediate relatives, not including parents, in the United States?
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Provide the following information: 
Surnames 
Given Names 
Relationship to You 
Relative's Status 
Do you have any immediate relatives, not including parents, in the United States? 
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Do you have any other relatives in the United States? 
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Spouse's Full Name (include Maiden Name)

Family Information: Spouse

NOTE: Enter current spouse information.
Spouse's Full Name (include Maiden Name)
Spouse's Surnames 
Spouse's Given Names 
Spouse's Date of Birth 
MM
/
DD
/
YYYY
Spouse's Country/Region of Origin
(Nationality)
City 
Country/Region 
Spouse's Address 
Present Work/Education/Training Information 
NOTE: Provide the following information concerning your current employment or education.
Primary Occupation 
Present Employer or School Name 
Street Address (Line 1)
City 
State/Province 
Postal Zone/ZIP Code 
Phone Number
Country/Region 
Start Date 
MM
/
DD
/
YYYY
Monthly Income in Local Currency (if employed) 
Briefly describe your duties: 
Previous Work/Education/Training Information 
NOTE: Provide your employment information for the last five years that you were employed, if
applicable. 
Were you previously employed?
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Have you attended any educational institutions at a secondary level or above?
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Provide the following information on the educational institution(s) you have attended. 
Name of Institution 
Street Address (Line 1)
City 
State/Province 
Postal Zone/ZIP Code 
Country/Region 
Course of Study
Date of Attendance From 
Date of Attendance To 
Help: Level of Education

You must answer Yes to this question if you have ever attended, for any length of time, a high
school/secondary school (or its equivalent in your country) or college, university, graduate school, a doctoral
program, or a vocational program. 
Were you previously employed? 
 *
Employer/Employment Information: 
Employer Name 
Employer Street Address (Line 1) 
City 
State/Province 
Postal Zone/ZIP Code 
Country/Region
Telephone Number
Job Title 
Supervisor's Surname 
Supervisor's Given Names 
Employment Date From 
Employment Date To 
Briefly describe your duties: 
Additional Work/Education/Training Information

NOTE: Provide the following work, education, or training related information. Provide complete and
accurate information to all questions that require an explanation.
Do you belong to a clan or tribe? 
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Provide a List of Languages You Speak 
Have you traveled to any countries/regions within the last five years? 
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Have you belonged to, contributed to, or worked for any professional, social, or charitable
organization?
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Do you have any specialized skills or training, such as firearms, explosives, nuclear, biological, or
chemical experience? 
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Have you ever served in the military? 
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Have you ever served in, been a member of, or been involved with a paramilitary unit, vigilante unit,
rebel group, guerrilla group, or insurgent organization?
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Have you traveled to any countries/regions within the last five years? 
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Provide a List of Countries/Regions Visited
Submit
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