hopeandlove

U.S. Department of State

Approved OMB 1405-0226

SUPPLEMENTAL QUESTIONS FOR VISA APPLICANTS

Expires xx/xx/xxxx

Estimated Burden 60 Minutes

General Instructions

• If you are unsure of the answer to a question, please provide a response to the best of your knowledge.  For example, if you are unsure of an exact address, provide the city, state, and street name if you can recall them.  U.S. Department of State will consider all information derived from the form in its entirety.

• Failure to answer every question will not necessarily preclude visa issuance, as the application is considered in its entirety.

• If you believe a particular question does not apply to you or your circumstances, please write "not applicable" or "N/A."

• If you need more space to response to a question, please write the rest of your response on a separate sheet of paper or email.

Surname(s):

Given Name(s):

Date of Birth (mm-dd-yyy):

Visa Type/Classification:

Passport and Travel History

Have you Travelled to any country (other than your country of residence) in the last 15 years?

If yes, provide details for each trip, including locations visited, date visited, source of funds, and length of stay.

Have you ever held a passport other than the passport listed in your visa application?

If yes, provide the following information.

Country of Issuance

Passport Number

Relatives

Siblings (brothers and sisters) - Provide the full name(s) and date of birth of any sibling (full, half, step, adopted), living or deceased.

Surname(s)

Given Name(s)

Date of Birth (mm-dd-yyy)

Children - Provide the full name (s) and date of birth of any child (minor and adult), living or deceased.

Surname(s)

Given Name(s)

Date of Birth (mm-dd-yyy)

Spouse - Provide the full name (s) of any current or previous spouse or civil/domestic partner, living or deceased.

Surname(s)

Given Name(s)

Date of Birth (mm-dd-yyy)

Address and Contact Information

Address - Provide all addresses where you have lived during the last 15 years, if not already provided in your application.

Address 1

Dates of Residence (mm-dd-yyyy):

Street Address 1:

Street Address 2:

City: 

State/Province:

Postal Zone/Zip Code:

Country/Region:

Address 2

Dates of Residence (mm-dd-yyyy):

Street Address 1:

Street Address 2:

City: 

State/Province:

Postal Zone/Zip Code:

Country/Region:

Phone Number - Provide all phone numbers you have used in the last five years, including primary, secondary, work, home, and mobile numbers

Phone Number (1):

Phone Number (2):

Phone Number (3):

Phone Number (4):

Phone Number (5):

Phone Number (6):

Phone Number (7):

Phone Number (8):

E-mail - Provide all email addresses you have used in th elast five years, including primary, secondary, work, personal, and educational addresses

E-mail Address (1):

E-mail Address (2):

E-mail Address (3):

E-mail Address (4):

E-mail Address (5):

E-mail Address (6):

Social Media

Please provide your unique user name for any websites or applications you have used to create or share content (photos, videos, status updates, etc.) as part of a public profile within the last five years.

Social Media Platform

Social Media Identifier (Name/Handle)

Employment History

Provide the following information on all employers in the last fifteen years, if not already provided in your application.

Employer 1 Name:

Dates of Employment (mm-dd-yyyy):

Street Address 1:

Street Address 2:

City: 

State/Province:

Postal Zone/Zip Code:

Country/Region:

Telephone Number: 

Job Title: 

Job Description: 

Employer 2 Name

Dates of Employment (mm-dd-yyyy):

Street Address 1:

Street Address 2:

City: 

State/Province:

Postal Zone/Zip Code:

Country/Region:

Telephone Number:

Job Title:

Job Description:

The information provided in this application and other information submitted may be provided to other U.S. government agencies having statutory or other lawful authority to use such information, including for law enforcement and immigration law enforcement purposes.  I understand that any willfully false or misleading statement or willful concealment of a material fact made by me herein may subject me to permanent exclusion from the United States and, if I am admitted to the United States, may subject me to criminal prosecution and/or removal.

Applicant's Signature:

Date (mm-dd-yyyy):

Paperwork Reduction Act Statement
Public reporting burden for this collection of information is estimated to average 60 minutes per response, including time required for searching existing data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final collection.  You do not have to supply this information unless this collection displays a currently valid OMB control number.  If you have comments on the accuracy of this burden estimate and/or recommendations for reducing it, please send them to: PRA_BurdenComments@state.gov.

CONFIDENTIALITY STATEMENT
AUTHORITIES: The information on this form is requested pursuant to Section 212(a) and 221 and as required by Section 222 of the Immigration and Nationality Act.  Section 222(f) provides that the records of the Department of State and of the diplomatic and consular offices of the United States pertaining to the issuance and refusal of visas or permits to enter the United States shall be considered confidential and shall be used only for the formultaion, amendment, administration, or enforcement of the immigration, nationality, and other laws of the United States.  Certified copies of such records may, in the discretion of the Secretary of State, be made available to a court provided the court certifies that the information contained in such records is needed in a case pending before the court.

PURPOSE: The U.S. Department of State uses the information provided on this form to determine an individual's eligibility for a U.S. visa.  Individuals who fail to submit this form or who do not provide all the requested information may be denied a U.S. visa.  Although furnishing this information is voluntary, failure to provide this information may delay or prevent the processing of an individual visa application.

DS-5535