APPLICANT INFORMATION FOR LOGGING IN U.S.

ONLINE VISA APPLICATION

1. Name as per Passport: EBENEZER SAMEDWIN

SURNAME: SAMEDWIN GIVEN NAME: EBENEZER
2. Sex: Male 3. Marital Status: Married

4. Date of Birth: NOVEMBER-01-1984 5. Place of Birth: CHENNAI

6. State of Birth: TAMIL NADU
6. Nationality: INDIAN 7. Other Nationalities:
8. Home Address: No V, IV th SCHEME, ICF COLONY, AYANAMPAKKAM ROAD, AMBATTUR, CHENNAI 600058

City: CHENNAI State/Province: TAMILNADU Pin code: 600058

9. Home Phone Number: +914479641932 Mobile/Cell Phone Number: 7550071336
10. Work Phone number: 9092133399 Work Fax Number:

10. Email Id: sebemajestic@gmail.com

11. Passport Number: Z4363350
12. Country/Authority That Issued Passport: INDIA
13. City Where Issued: CHENNAI
14. Issuance Date: 06/10/2017 15.Expiration Date: 05/10/2027
16. Have you ever lost a Passport or had one Stolen? Y/ N

TRAVEL INFORMATION

17. Purpose of your trip to U.S.: PILOT TRAINING

18. Intended Date of Arrival:

19. Person/Entity Paying for your Trip: Self / Other Person/ Company / Organization

20. Name of the Person/ Entity paying for your trip:

Relationship to you:
Email Address:
Address of the Person/ Entity paying for your trip:

Telephone no. of the Person/ Entity paying for your trip:

21. Other Persons traveling with you (mention the relationship with you):

22. Have You Ever Been in the U.S.? Y/ N Date:

Total Days (Each Entry):

23. Have You Ever Issued a U.S.Visa? Y/ N

Type of Visa: Date of Issue:
Issued Visa Number: (Please Provide the number mentioned below EXPIRY DATE OF VISA)

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24. Do you have US Driver’s License? Y/N

25. Have you ever been refused a U.S. visa? Y/ N Date of refusal:
Where: Type of Visa:
REASON FOR REFUSAL:

26. Admission to the U.S, or withdrawn your application for admission at the point of entry? Y/N

FAMILY INFORMATION

27. Father’s Surname: RAMASWAMY Father Given Name:. SAMEDWIN

28. Father’s Date of Birth: OCTOBER-16-1948 29. Is Your Father In the U.S? Y / N

30. Mother’s Surname: NALLAMAL JAIN Mother’s Given Name: SUGUNA SELEE
31. Mother’s Date of Birth: APRIL-06-1955 32. Is Your Mother In the U.S? No

33. Do you have any immediate relatives not including parents in the U.S? : No

34. Do you have any other relatives in the U.S? No

35. Relation with the applicant:

36. Nationality of the person in USA (US GREEN CARD/PERMANENT RESIDENT/US CITIZEN/NON IMMIGRANT):

37. Spouse’s Full Name: JANICE TORRES GAYLA

Spouse’s Surname: GAYLA Spouse’s Given Name: JANICE
38. Spouse’s Date of Birth: August 03, 1980 39. Spouse’s Nationality: FILIPINO

40. Spouse’s City of Birth: Cabanatuan City 41. Spouse’s Country of Birth: Philippines

42. Spouse’s Address: No V, IV th SCHEME, ICF COLONY, AYANAMPAKKAM ROAD, AMBATTUR, CHENNAI 600058

WORK/ EDUCATION / TRAINING INFORMATION

(For Retired person mention previous employment details)

43. Primary Occupation: BUSINESS, SELF

44. Present Employer / School Name: VERITASTECH

45. Address: No V, IV th SCHEME, ICF COLONY, AYANAMPAKKAM ROAD, AMBATTUR, CHENNAI 600058

City: CHENNAI State/Province: TAMIL NADU

Postal Zone/Zip Code: 600058 Country: INDIA

50. Supervisor Name: SELF Telephone no.: 7550071336

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51. Job Title: CEO & DIRECTOR
51. Monthly Salary in Local Currency:
52. Employment Date From: MARCH 2009 Employment Date To: November 2019
53. Briefly Describe your Duties: Lean Six Sigma Trainer & Consultant.

54. Were you previously employed? (LAST FIVE YEARS) Y/N

Employer Name:
Employer Address :

City: State/Province :
Postal Zone/Zip Code: Country:
Supervisor Name: Telephone no.:
Job Title:
Employment Date From: Employment Date To:
Briefly Describe your Duties:

55. Educational details:

Name of the Institution Address/Tel no Course of Study Date of attendance (MM-DD-YY)
1) Liverpool John Moore's University Liverpool, UK MBA From 09-15-2007 To 02-15-2009
2) Anna University. Anna University, Chennai Industrial Engineering From 07-12-2003 To. 05-15-2007
3). SBOA school. SBOA, School, Chennai Higher Secondary From 06-10-2001 To. O4-12-2003

56. Travel History of last 5 years (Country along with Year of Each Visit)
Dec 07th 2017 till 4th Jan 2018 Holiday in Phillipines.

57. Languages you speak? English, Tamil

SECURITY AND BACKGROUND INFORMATION (PLEASE TICK YES OR NO)

58. Do you have a communicable disease of public health significance such as Tuberculosis (TB)? Y/N

59. Do you have a mental or physical disorder that poses or is likely to pose a threat to the safety or welfare of yourself or others? Y/ N

60. Are you or have you ever been a drug abuser or addict? Y/N

61. Have you ever been arrested or convicted for any offense or crime, even though subject of a pardon, amnesty, or other similar action?
Y/N

62. Have you ever violated, or engaged in a conspiracy to violate, any law relating to controlled substances? Y/N

63. Are you coming to the U.S. to engage in prostitution or unlawful commercialized vice or have you been engaged in prostitution
procuring prostitutes within the past 10 years? Y/N

64. Have you ever been involved in, or do you seek to engage in money laundering? Y/ N

65. Do you seek to engage in espionage, sabotage, export control violations, or any other illegal activity while in the U.S? Y/N

66. Do you seek to engage in terrorist activities while in the U.S or have you ever engaged in terrorist activities? Y/N

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67. Have you ever or do you intend to provide financial assistance or other support to terrorists or terrorist organizations? Y/ N

68. Are you a member or representative of a terrorist organization? Y/N

69. Have you ever ordered, incited, committed, assisted, or otherwise participated in genocide? Y/ N

70. Have you ever committed ordered, incited, committed, assisted, or otherwise participated in Torture? Y/N

71. Have you ever committed ordered, incited, committed, assisted, or otherwise participated in extra judicial killings, political killings,
or other acts of violence? Y/N

72. Have you, while serving as a government official, been responsible for or directly carried out, at any time, particularly severe violations of religious freedom?
Y/ N

73. Have you ever sought to obtain or assist others to obtain a visa, entry in to the U.S, or any other U.S immigration benefit by fraud or willful misrepresentation or
other unlawful means? Y/ N

74. Have you ever with held custody of a U.S. citizen child outside the U.S. from a person granted legal custody by a U.S. court? Y/ N

75. Have you ever voted in the U.S. in the violation of any Law or regulation? Y/N

76. Have you ever renounced U.S. citizenship for the purpose of avoiding taxation? Y /N

UNDERTAKING BY THE PASSENGER

I, MR/MRS/MS/MSTR …………………………………………………………….HEREBY DECLARE THAT THE ABOVE FURNISHED INFORMATION GIVEN BY ME FOR U.S.A ONLINE VISA PROCESSING ARE
TRUE TO THE BEST OF MY KNOWLEDGE & I CLEARLY UNDERSTAND THE SERIOUSNESS OF PROVIDING FALSE OR WRONG INFORMATION WOULD RESULT IN VISA INELIGIBILITY TO THE
UNITED STATES OF AMERICA.

DATE:
PLACE: SIGNATURE