Consular Electronic Application Center - Print Application Page 1 of 4 Nonimmigrant Visa Application Application - Sensitive But Unclassified(SBU) Photo Provided: SAMPLE - IMMIHELP.COM Confirmation Number: Personal, Address, Phone, and Passport Information Name Provided: Full Name in Native Language: ▲ Other Names Used: Other Name (1) : GUPTA , RAMESH DOES NOT APPLY YES NONE , RAMESHBHAI Sex: Marital Status: Date of Birth: Place of Birth: Nationality: Other Nationalities: MALE MARRIED 01 JANUARY 1945 MUMBAI , MAHARASHTRA , INDIA INDIA NO National Identification Number: U.S. Social Security Number: U.S. Taxpayer ID Number: Home Address: City: State/Province: Postal Zone/ZIP Code: Country: Same Mailing Address? Home Phone Number: Work Phone Number: Work Fax Number: Mobile/Cell Phone Number: Email Address: Passport Number: Passport Book Number: Country/Authority that Issued Passport: City Where Issued: State/Province Where Issued: Country Where Issued: Issuance Date: Expiration Date: Have you ever lost a passport or had one stolen? DOES NOT APPLY DOES NOT APPLY DOES NOT APPLY 34 SHANKAR LANE BORIVALI MAHARASHTRA 400034 INDIA YES 91-22-5555-1111 91-22-5555-1111 91-22-5555-1111 91-22-5555-1111 [email protected] A9783434 DOES NOT APPLY INDIA MUMBAI MAHARASHTRA INDIA 10 JANUARY 2009 28 JANUARY 2019 NO Travel Information Consular Electronic Application Center - Print Application Principal Applicant? YES ▲ Purpose of Your Trip to U.S. Purpose (1) : TOURIST/PERSONAL TRAVEL VISITOR (B2) Intended Date of Arrival: Intended Length of Stay in U.S.: Address where you will stay in the U.S: 29 JUNE 2010 6 MONTH(S) 123 PARK AVENUE EDISON, NEW JERSEY 08817 Person/Entity Paying for Your Trip: OTHER PERSON Name of Person Paying for Your Trip: GUPTA , RAHUL Telephone: 732-555-1212 Email Address: [email protected] Relationship to You: CHILD Is the address of the party paying for your trip the NO same as your Home or Mailing Address? Paying Address: 123 PARK AVENUE City: EDISON State/Province: NJ Postal Zone/ZIP Code: 08817 Country: UNITED STATES OF AMERICA ▲ Other Persons Traveling with You: YES Are you traveling as part of a group or organization? Persons Traveling with You: Name (1) : Relationship to You: NO 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 Have you ever been refused a U.S. Visa, been refused admission to the United States, or withdrawn your application for admission at the point of entry? NO NO NO GUPTA , RAMILA SPOUSE U.S. Contact Information Contact Person Name in the U.S.: Organization Name in the U.S.: Relationship to You: U.S. Contact Address: Phone Number: Email Address: GUPTA, RAHUL DO NOT KNOW RELATIVE 123 PARK AVENUE EDISON, NEW JERSEY 08817 (732)555-1212 [email protected] Family Information Father's Surnames: Father's Given Names: Father's Date of Birth: Is your father in the U.S.? Mother's Surnames: Mother's Given Names: Mother's Date of Birth: Is your mother in the U.S.? ▲ Do you have any immediate relatives, not including parents in the U.S.? Relative Name (1) : Relationship to you: Status: Spouse's Spouse's Spouse's Spouse's Full Name: Date of Birth: Nationality: City of Birth: GUPTA AMRIT 10 JANUARY 1933 NO GUPTA SAVITA 10 FEBRUARY 1934 NO YES GUPTA , RAHUL CHILD U.S. CITIZEN GUPTA , RAMILA 29 MARCH 1947 INDIA DELHI Page 2 of 4 Consular Electronic Application Center - Print Application Spouse's Country of Birth: Spouse’s Address: INDIA SAME AS HOME ADDRESS Work / Education / Training Information Primary Occupation: Present Employer or School Name: Address: City: State/Province: Postal Zone/Zip Code: Country: Month Salary in Local Currency: Briefly Describe your Duties: BUSINESS STAR BAZAAR 2345 KHAR LANE MUMBAI MAHARASHTRA 400011 INDIA 45,000 SALESMAN Security and Background Information Do you have a communicable disease of public health significance such as tuberculosis (TB)? 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? Are you or have you ever been a drug abuser or addict? Have you ever been arrested or convicted for any offense or crime, even though subject of a pardon, amnesty, or other similar action? Have you ever violated, or engaged in a conspiracy to violate, any law relating to controlled substances? Are you coming to the United States to engage in prostitution or unlawful commercialized vice or have you been engaged in prostitution or procuring prostitutes within the past 10 years? Have you ever been involved in, or do you seek to engage in, money laundering? Do you seek to engage in espionage, sabotage, export control violations, or any other illegal activity while in the United States? Do you seek to engage in terrorist activities while in the United States or have you ever engaged in terrorist activities? Have you ever or do you intend to provide financial assistance or other support to terrorists or terrorist organizations? Are you a member or representative of a terrorist organization? Have you ever ordered, incited, committed, assisted, or otherwise participated in genocide? Have you ever committed, ordered, incited, assisted, or otherwise participated in torture? Have you committed, ordered, incited, assisted, or otherwise participated in extrajudicial killings, political killings, or other acts of violence? Have you, while serving as a government official, been responsible for or directly carried out, at any time, particularly severe violations of religious freedom? Have you ever sought to obtain or assist others to obtain a visa, entry into the United States, or any other United States immigration benefit by fraud or willful misrepresentation or other unlawful means? NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO Have you ever withheld custody of a U.S. citizen NO child outside the United States from a person granted legal custody by a U.S. court? Have you voted in the United States in violation of NO Page 3 of 4 Consular Electronic Application Center - Print Application any law or regulation? Have you ever renounced United States citizenship for the purpose of avoiding taxation? NO Location Information Current Location: 080%$,,1',$ Preparer of Application: Did anyone assist you in filling out this application? NO Page 4 of 4