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21 February, 2019

$99.00

Visa USA Application

Please provide all responses in English

1 Personal and Travel Information

2 Confirm your details

3 Payment method

Applicant Information
First Name*

In the First Name field, enter your first name as the first name appears on your passport under the First or Given Name field. The first name is required to complete the application. If you have no first name, then enter the letters FNU which stands for First Name Unknown.

Enter your First Name as shown on your passport
Family Name*

In the Family Name field, enter your family name as the family name appears on your passport under the Family Name or Surname field. The family name is required to complete the application.

Enter your Family Name as shown on your passport
Gender*
- Female
- Male
Birth Date*

In the Birth Date field, chose the day on which you were born. The day of birth is required to complete the application
*
*
City of Birth*

Enter the city, town, village, or hamlet in which you were born. The city, town, village, or hamlet where you were born is required to complete the application. If you do not know the city in which you were born, enter UNKNOWN.
Country of Birth*

In the Country field, choose the country. The country is required to complete the application.

Country
Mother's Name*

Enter the names of your parents. These are required to complete the application. If you do not know the name of one or both of your parents, enter UNKNOWN, for each parent. This field can include the names of your biological, adoptive, step-parent or guardian.
Mother's Last Name*

Enter the names of your parents. These are required to complete the application. If you do not know the name of one or both of your parents, enter UNKNOWN, for each parent. This field can include the names of your biological, adoptive, step-parent or guardian.
Father's Name*

Enter the names of your parents. These are required to complete the application. If you do not know the name of one or both of your parents, enter UNKNOWN, for each parent. This field can include the names of your biological, adoptive, step-parent or guardian.
Father's Last Name*

Enter the names of your parents. These are required to complete the application. If you do not know the name of one or both of your parents, enter UNKNOWN, for each parent. This field can include the names of your biological, adoptive, step-parent or guardian.
Contact Information
E-mail Address*

Enter the e-mail address at which you can be contacted. The e-mail address is required to complete the application. If you do not have an e-mail address, you may provide an alternative third-party e-mail address belonging to a point of contact (e.g. a family member, friend or business associate).
Confirm E-mail Address*

Enter the e-mail address at which you can be contacted. The e-mail address is required to complete the application. If you do not have an e-mail address, you may provide an alternative third-party e-mail address belonging to a point of contact (e.g. a family member, friend or business associate).
Telephone Number*

The telephone number is required to complete the application. If you do not have a telephone number, you may provide an alternative third-party telephone number where you can be contacted (e.g. a family member, friend, or business associate).
Address Line*

In the Address Line field, enter the number and street of the location of your home address. Do not include the city and state in this field. Address line is required to complete the application.
Apartment Number

In the Apartment Number field, enter apartment, suite, unit, or other, as appropriate. Do not include the city and state in this field. Apartment number is optional to complete the application.
City*

In the City field, enter the city, town, village, or hamlet. The city, town, village, or hamlet is required to complete the application.
State/Province/Region*

In the State/Province/Region field, enter the state, province, or region. The State/Province/Region is required to complete the application.
Country*

In the Country field, choose the country. The country is required to complete the application.
Employment Information
Do you have a current or previous employer?*
- Yes
- No
Job Title*
Employer Name*

Enter the name of your current employer. If you are not currently employed, enter the name of your previous employer. Employer name is required to complete the application. You may also enter SELF-EMPLOYED, STUDENT, CHILD, HOMEMAKER, STAY-AT-HOME PARENT, or any other word to describe your employment status.
Address Line*

Please enter the address (street and number) of your employer.
Post Code

Please enter required Post Code. If you do not know the Post Code, enter two zeros (00) in order to proceed with the application.
City

In the City field, enter the city, town, village, or hamlet. The city, town, village, or hamlet is required to complete the application.
State/Province/Region

In the State/Province/Region field, enter the state, province, or region. The State/Province/Region is required to complete the application.
Country

In the Country field, choose the country. The country is required to complete the application.

Country
Phone*
Emergency Contact Information In or Out of the United States
Emergency Contact First Name

In the First (Given) Name field, enter the emergency contact’s first name. You must complete this field to complete the application. If you have no emergency contact (or your contact has only one name), enter UNKNOWN.
Emergency Contact Last Name

In the Family Name field, enter your emergency contact’s family name. You must complete this field to complete the application. If you have no emergency contact, enter UNKNOWN.
Telephone Number

Enter your emergency contact's telephone number. The number is required to complete the application. If you do not know the telephone number, you may provide an alternative third-party telephone number (e.g. belonging to a family member, friend, or business associate).
E-mail Address

Enter your emergency contact's e-mail address. E-mail address is required to complete the application. You may also enter UNKNOWN.
Travel Information
Is your travel to the US occurring in transit to another country?*
- Yes
- No
US Point of Contact

A U.S. point of contact may be a friend, relative, or business associate. If you do not have a U.S. point of contact, please enter the name, address and telephone number of the location where you will be staying (e.g. a hotel name). You may also enter UNKNOWN.
Address

In the Address Line field, enter the number and street of your US point of contact's address. Do not include the city and state in this field. Address line is required to complete the application. You may also enter UNKNOWN.
City*

In the City field, enter the city, town, village, or hamlet. The city, town, village, or hamlet is required to complete the application.
Passport Information
Country of Citizenship*

Choose the country of citizenship, as it appears on your passport. The country of citizenship is required to complete the application.
National Identification Number*

Enter your personal identification number as it appears on your passport. The personal identification number starts with an English letter followed by 9 numbers. The Personal Identification Number is required to complete the application.
Passport Issuing Country*

Choose the country of citizenship, as it appears on your passport. The passport issuing country is required to complete the application.
Passport number*

Enter your passport number as it appears on your passport. The passport number may contain numbers and/or characters. Please closely distinguish between the number zero and the letter O. The passport number is required to complete the application or to check the status of your application.
Repeat Passport number*

Enter your passport number as it appears on your passport. The passport number may contain numbers and/or characters. Please closely distinguish between the number zero and the letter O. The passport number is required to complete the application or to check the status of your application.
Passport Issuance Date*

In the Day field, choose the day on which your passport was issued, as it appears on your passport under the Date of Issue field. The day on which the passport was issued is required to complete the application. In the Month field, choose the month in which your passport was issued, as it appears on your passport under the Date of Issue field. The month in which the passport was issued is required to complete the application. In the Year field, choose the year in which your passport was issued, as it appears on your passport under the Date of Issue field. The year in which the passport was issued is required to complete the application.
*
*
Passport Expiration Date*

In the Day field, choose the day on which your passport expires, as it appears on your passport under the Expiration Date field. The day on which the passport expires is required to complete the application. In the Month field, choose the month in which your passport expires, as it appears on your passport under the Expiration Date field. The month in which the passport expires is required to complete the application. In the Year field, choose the year in which your passport expires, as it appears on your passport under the Expiration Date field. The year in which the passport expires is required to complete the application.
*
*
Have you ever been issued a passport or national identity card for travel by any other country?*
- Yes
- No
Issuing Country*

In the Country field, choose the country. The country is required to complete the application.

Country
Document Type*

Please select the travel document type issued by another country.
Document Number*

Enter your document number as it appears on your travel document. The travel document may contain numbers and/or characters. Please closely distinguish between the number zero and the letter O.
Expiration date*

Please type in the expiration date from the document. If the expiration date is UNKNOWN enter 0000.
Are you now, a citizen or national of any other country?*
- Yes
- No
Country of Citizenship / Nationality*

In the Country field, choose the country. The country is required to complete the application.

Country
How did you acquire citizenship / nationality from this country?*

Please indicate how did you acquired citizenship/nationality.
Have you ever been a citizen or national of any other country?*
- Yes
- No
Country of Citizenship / Nationality*

In the Country field, choose the country. The country is required to complete the application.

Country
GE Membership
Are you a member of the CBP Global Entry Program?*
- Yes
- No
Membership Number*

The Membership Number is exactly nine digits. It is labeled as Membership Number / PASSID and can be found by logging into your GOES account.
Do any of the following apply to you? (Change to Yes if applicable)
Do you have a physical or mental disorder; or are you a drug abuser or addict; or do you currently have any of the following diseases (communicable diseases are specified pursuant to section 361(b) of the Public Health Service Act):
- Cholera
- Difteria
- Infectious tuberculosis
- Plague
- Smallpox2
- Yellow fever
- Viral Hemorrhagic Fevers, including Ebola, Lassa, Marburg virus disease, Crimean-Congo
- Severe acute respiratory illnesses capable of transmission to other persons and likely to cause mortality
*
You will be able to continue only if the selection is no.
- Yes
- No
Have you ever been arrested or convicted for a crime that resulted in serious damage to property, or serious harm to another person or government authority?*
You will be able to continue only if the selection is no.
- Yes
- No
Have you ever violated any law related to possessing, using, or distributing illegal drugs?*
You will be able to continue only if the selection is no.
- Yes
- No
Do you seek to engage in or have you ever engaged in terrorist activities, espionage, sabotage, or genocide?*
You will be able to continue only if the selection is no.
- Yes
- No
Have you ever committed fraud or misrepresented yourself or others to obtain, or assist others to obtain, a visa or entry into the United States?*
You will be able to continue only if the selection is no.
- Yes
- No
Are you currently seeking employment in the United States or were you previously employed in the United States without prior permission from the U.S. government?*
You will be able to continue only if the selection is no.
- Yes
- No
Have you ever been denied a U.S. visa you applied for with your current or previous passport, or have you ever been refused admission to the United States or withdrawn your application for admission at a U.S. port of entry?*
You will be able to continue only if the selection is no.
- Yes
- No
Have you ever stayed in the United States longer than the admission period granted to you by the U.S. government?*
You will be able to continue only if the selection is no.
- Yes
- No
Have you traveled to, or been present in Iraq, Syria, Iran, Sudan, Libya, Somalia or Yemen on or after March 1, 2011?*
You will be able to continue only if the selection is no.
- Yes
- No

Please confirm your details:
{all_fields}
*
- I confirm that the above information is true and correct.
*
- I have read and understood and accept the terms and conditions, refund policy and privacy policy
Name
This field is for validation purposes and should be left unchanged.

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