US VISA QUESTIONNAIRE

PLEASE ANSWER IN CAPITAL LETTER AND IN BOLD FONT. PUT N/A IF NOT APPLICABLE

PERSONAL INFORMATION
Surname: Given Name/s:

Other Names Used (IF APPLICABLE):

[Maiden Name, Religious Name, Professional Name, Alias, etc.]

Surname: Given Name/s:

Gender: Date of Birth (DD-MM-YYYY):

If Married; Date of
Marital Status:
Marriage (DD-MM-YYY):

If Separated or Divorced; Date Ended (DD-MM-YYY):

If Separated or Divorced; please provide reason:

Country/Region of Origin (Nationality):

YES OR NO Do you hold or have you held any Nationality other than the one indicated above?
If yes, please advise other country/region of Origin:

Do you hold a Passport for the other country/region of origin (Nationality) indicated
YES OR NO
above?
If yes, please provide Passport Number:

Are you a Permanent Resident of a country/region other than your country of Origin
YES OR NO
(Nationality) indicated above?
If yes, please advise other Permanent
Resident Country/Region:

Complete Home Address with Zip Code:

Complete Mailing Address with Zip Code:

Personal Landline Personal Mobile

Number: Number:
Work Phone
Email Address:
Number:
Passport/Travel Passport/Travel
ORDINARY or DIPLOMAT
Document Type: Document Number:
Country/Authority that Issued Place where the Passport/Travel
Passport/Travel Document: Document was Issued:
Issuance Date (DD-MM-
Expiration Date (DD-MM-YYYY):
YYYY):

YES OR NO Have you ever lost a Passport or had one stolen?

 If yes, please provide the following information:
Country/Authority that issued
Passport Number: Reason:
Passport/Travel Document:

Social Media links:

PURPOSE OF YOUR TRIP TO US

Reason for visiting the US (be specific):

Intended date of Entry Intended length of stay

to US (DD-MM-YYYY): in US:

Who will pay for your trip:

Surname of Person Paying Given Name of Person Paying

Relationship to Applicant:
for the trip: for the Trip:

Financer’s Contact Financer’s Email

Number: Address:
Financer’s Complete Home Address
with Zip Code:

If a company or organization will finance your trip, please fill up the following:

Name of Contact Number of

Company/Organization Company/Organization Paying Relationship to the Applicant:
paying for the trip: for the trip:

Financer’s Complete Mailing

Address with Zip Code:

ADDRESS WHERE YOU WILL STAY IN THE US

Street Address (Line 1):

City
State: Zip Code:
:

YES OR NO Are there other person traveling with you?

YES OR NO Are you traveling as part of a group or organization?

If you are travelling as part of a group or organization, fill up the details below:

Surname of person traveling Given Names of person

Relationship to you:
with you: traveling with you
 1.

2.

3.

4.

YES OR NO Have you ever been in the US?

If yes, provide the dates covered
(DD-MM-YYYY):

YES OR NO Do you or did you ever hold a U.S. Driver’s License?

YES OR NO Have you ever been issued a U.S. Visa?

If yes, provide the following information:

Previous Visa Number:

Issuance Date (DD-MM-YYYY):

YES OR NO Are you applying for the same type of visa?

Are you applying in the same country or location where the visa above was issued & is
YES OR NO
this country or location your place of principal residence?

YES OR NO Have you been ten-printed?

YES OR NO Has your U.S. visa ever been lost or stolen?

If yes, please advise when you lost it and explain:

YES OR NO Has your U.S. visa ever been cancelled or revoked?

If yes, please explain:

Have you ever been refused a U.S. Visa or been refused admission to the United States
YES OR NO
or withdrawn your Application for Admission at the port of Entry?
If yes, please explain:

Has anyone ever files an Immigrant Petition on your behalf with the United States
YES OR NO
citizenship and immigration services?
If yes, please explain:

CONTACT PERSON OR ORGANIZATION IN THE UNITED STATES

Surname: Given Names:
Organizatio
Relationship to you:
n Name:

U.S. Street Address (Line 1): City:

State: Zip code (if known):

Phone Number: Email Address:

FAMILY INFORMATION
FATHER’S INFORMATION
Full Name: Date of Birth (DD-MM-YYY):

YES OR NO Is your father in the U.S.?

If yes, please advise status. (US Citizen, US Legal Permanent Resident or
Nonimmigrant)

MOTHER’S INFORMATION
Full Name: Date of Birth (DD-MM-YYY):

YES OR NO Is your mother in the U.S.?

If yes, please advise status. (US Citizen, US Legal Permanent Resident or
Nonimmigrant)

YES OR NO Do you have any immediate relatives, not including parents, in the United States?
If yes, please provide the following:

Relative 1
Surname: Given Name:

Relationship to Status in USA

(Citizen / Permanent
the Applicant: Resident / Nonimmigrant)

Relative 2
Surname: Given Name:

Relationship to Status in USA

(Citizen / Permanent
the Applicant: Resident / Nonimmigrant)

Do you have any other relatives not including parents or immediate relatives in the
YES OR NO
United States?
If yes, please provide the following:

Relative 1
Surname: Given Name:

Relationship to Status in USA

(Citizen / Permanent
the Applicant: Resident / Nonimmigrant)

SPOUSE INFORMATION
Full Name: Date of Birth (DD-MM-YYY):
(include Maiden Name)
Nationality: Place of Birth:

Complete address with Zip Code:

YES OR NO Do you have children / dependents?

If yes, kindly fill up the details below:
Full Name Age
1.
2.
3.
4.
5.

CURRENT WORK / EDUCATION

Primary Occupation / Student:

Present Employer / Name of School:

Complete employer’s / school’s address

with Zip Code and contact Number:

When did you start working for the company / when did you
enter the school? Exact dates needed (DD-MM-YYYY)

What is your job responsibility?

What is the source of How much do you

your monthly income? earn per month (PHP)?
How much is your
How much is your current balance in
Average Daily Balance
your bank account (PHP)? for the past 6 months?

How much is your pocket money to the US?

PREVIOUS EMPLOYMENT
Previous Employer Name:

Job Title and brief description of your

duties:

Previous employer’s complete address

with zip code and contact number:

EMPLOYMENT PERIOD Start date (DD-MM-YYYY):

End date (DD-MM-YYY):
Supervisor’s Surname: Supervisor’s Given Name:

YES OR NO Have you attended any educational institutions at a secondary level or above?
If yes, please fill up the details below:
Name of Institution:
ADDRESS
Street Address:
City and State/Province:
Zip Code:
Country/Region:
Course of Study:
Attendance Start date (DD-MM-YYYY):
End date (DD-MM-YYYY):

TRAVEL HISTORY
Countries Visited in the past 5 years Arrival and Departure Date
1.
2.
3.
4.
5.
6.
7.
8.

BACKGROUND AND SECURITY QUESTIONS

YES OR NO Do you belong to a clan or tribe?
If yes, provide Clan or Tribe Name:

Provide a list of Languages you speak:

Have you belonged to, contributed to, or worked for any professional, social, or
YES OR NO
charitable organization?
If yes, please provide Organization Name:

Do you have any specialized skills or training, such as firearms, explosives, nuclear,
YES OR NO
biological, or chemical experience?
If yes, please explain:
YES OR NO Have you ever served in the military?
If yes, please provide the following information:
Name of Country/Region:
Branch of Service: Rank:
Military Specialty:
Date of Service From (DD-MM-YYY):
Date of Service To (DD-MM-YYYY):

Have you ever served in, been a member, or been involved with paramilitary unit,
YES OR NO
vigilante unit, rebel group, guerilla group, or insurgent organization?
If yes, please explain:

YES OR NO Do you have communicable disease of public health significance?

If yes, please explain:

Do you have mental or physical disorder that poses or is likely to pose a threat to the
YES OR NO
safety or welfare of yourself or others?
If yes, please explain:

YES OR NO Are you or have you ever been a drug abuser or addict?
If yes, please explain:

Have you ever been arrested or convicted for any offense or crime even though subject
YES OR NO
for pardon, amnesty or other similar action?
If yes, please explain:

Have you ever violated, or engaged in a conspiracy to violate, any law relating to
YES OR NO
controlled substances?
If yes, please explain: