Surname：
Given Name: / Other
Names Used： / Date of Birth（D/M/Y）: / Nationality：
Place of Birth: / Which City AuthorityPassport ： / PassportNumber:
Marital Status: / If Divoced，Please fill the information for below：
Date of Marriage（D/M/Y）: Date Marriage Ended（D/M/Y）
Resident address:
Zip code： / Mobile phone No：
Secondary Phone Number（If have）
：
Work Phone Number：
ID Number: / E-mail address：
Persons Traveling with You If have，Please fill the information for below:
If haven’t Please fill the“/“in the form
Surname：
Given Name / Nationality / Do he/she have us visa， / Relationship to You:

U.S.A. Application Form

Previous U.S. Travel Information

Have you ever been in the U.S.? / Yes/No：If yes please providd：1.Date Arrived（D/M/Y）:
2. Length of Stay:
Have you ever been issued a U.S. Visa? / Yes/No：If yes please providd1. Date Last Visa was Issued
2Visa Number:
Have you ever been refused a U.S. Visa, or been refused
admission to the United States, or withdrawn your applicationfor admission at the port of entry? / Yes/No：
If yes please provided when be refused
Has anyone ever filed an immigrant petition on your behalf
with the United States Citizenship and Immigration Service / Yes/No：
If yes please provided when apply

Travel information

Intended Date of Arrival / Intended Length of Stay in U.S.:
Address where you will stay in the U.S.: / Zip Cope：
Hotel Name/Inviter / Contact No.：
E-mail address：
Person/Entity Paying for Your Trip::
Purposes of Trip to the U.S.:

Education

Name of Institution / Course of Study: / Address of Institution
Middle School / Date of Attendance From: ——
Date of Attendance To:
Senior Middle School / Date of Attendance From: ——
Dateof Attendance To:
University / Date of Attendance From: ——
Date of Attendance To:

Work Information

Present
Present Employer or School Name::
Job Title: Monthly Salary in Local Currency:
Work Phone Number:
Address: Zip Code:
previously employed
Employer Name / Employer Address / Telephone Number / Job Title / Supervisor's Name
Employment Date From:
Employment Date To:
Employment Date From:
Employment Date To:

Family Information

Surname：
Given Name: / Date of Birth（D/M/Y） / Address to live / City of Birth
Father
Mother
Spouse /former Spouse

Background

Do you have any immediate relatives, not including parents inthe U.S.? Yes or No
If have please provide 1 Surname ：Given Name： 2 Relationship to You： 3Relative's Status
Do you have any other relatives in the United States? Yes or No
Have you ever lost a passport or had one stolen?Yes or No
If Have Please provide the year of passport lost or stolen
Have you traveled to any countries within the last fiveyears Yes or No
If yes please list：
Provide a List of Languages You Speak: