Applicant Data

Consult your passport and enter all the data in the same format.

Personal information

Other Citizenship/Nationality

Are you now a citizen or national of any other country ? *
YesNo

Have you been a citizen or national of another country? *
YesNo

IMPORTANT: Your application number will be sent to the email address listed below. You must verify your email address to complete your request.

Additional Information

Please give all answers in English.

Are you known by any other names or aliases ?
YesNo

Have you ever had a passport or national identity card issued to you by another country to travel?
YesNo

Your home address

Parents

Please provide the names of your parents:

Father

Mother

Employment Information

Do you have a job?

YesNo

Trip Information

Is your trip to the United States a transit to another country ?
YesNo

Emergency Contact Information In Or Outside The United States

Do you have a copy of your passport to download?

Eligibility Questions

Do you suffer from a physical or mental illness, are you a drug addict or chronic drug addict or do you suffer from any of the following illnesses : Chancroid, Gonorrhea, Granuloma inguinale, Infectious leprosy, Lymphogranuloma venereum, Infectious syphilis, Active tuberculosis? :
YesNo

Have you been arrested or convicted of an offense that caused serious property damage or serious harm to another person or government authority ?
YesNo

Have you ever violated any law in connection with the possession, use or trafficking of illegal drugs ?
YesNo

Do you intend to participate or have you participated in terrorist activities, espionage, sabotage or genocide ?
YesNo

Have you ever committed fraud or misrepresented yourself or others to obtain or assist others in obtaining a U.S. visa or entry ?
YesNo

Are you currently seeking employment in the United States or have you worked in the United States in the past without obtaining prior permission from the U.S. government ?
YesNo