U.S. Visa Questionnaire

Name (Required)

Date of Birth

Passport Number

Personal Information

Current Resident Address

Primary Phone Number

Secondary Phone Number

Travel Information

Purpose of Your Trip to the United States

Address Where You Will Stay in the United States

Who Will Be Paying for Your Trip?

Is a Company or Organization Paying for Your Trip?

Yes No

Company/Organization Name

Company/Organization Telephone Number

Company/Organization Address

Are There Any Other Persons Traveling with You?

U.S. Travel History

Have You Ever Been in the United States Before?

Have You Ever Been Issued a U.S. Visa?

Have You Ever Been Refused a U.S. Visa?

Have You Ever Stayed in the U.S.?

Do You Have a Contact Person in the U.S.?

Yes No

Name of Contact Person

Organization Name

Contact Address

Contact Phone Number

Contact Email Address

Have you traveled to any countries/regions within the last five years?

Yes No

Family Information

Father's Full Name

Father's Date of Birth

Mother's Full Name

Mother's Date of Birth

Spouse's Full Name

Spouse's Date of Birth

Do you have any immediate relatives, not including your parents, in the United States? If yes, provide details.

Education Information

Have You Attended Any Educational Institutions?

Yes No

Institution Name

Course of Study

Date of Attendance (From and To)

Present Work Information

Employer Name

Job Title

Employment Dates

Previous Employment Information

Were You Previously Employed?

Yes No

Employer Name

Job Title

Employment Dates