DS 160 Questionnaire

IF YOU WRITE YOUR ANSWERS, USE BLACK INK. MAKE SURE YOUR ENTRIES ARE NEAT LEGIBLE AND WITHIN THE SPACE PROVIDED.
Information as it is written on your passport. Put N/A on the field if Not Applicable.

Personal Information
Surname:
Given Name:
YES NO
Have you ever used other names (i.e., maiden, religious, professional, alias, etc.)?
Do you have telecode that represents your name?

Sex: Male Female

Marital Status: Divorced Widowed Single Married
Date and Place of Birth
Date of Birth (dd/mm/yyyy):
City:
State/Province:
Country:
Nationality:
YES NO

Do you hold or have held any nationality other than the one indicated above on nationality?

Are you a permanent resident of a country/region other than your country/region on origin
indicated above?
National Identification Number:
U.S. Social Security Number:
U.S. Taxpayer ID Number:
Travel Information:
Purpose of the Trip to the US:
Specify:
USCIS Case number (eg., ABC1234567890):
Have you made specific travel plans? YES NO
Intended Date of Arrival (dd/mmm/yyyy):
Address Where You Will Stay in the U.S.
Street Address:
City:
State:
Zip Code:
Person/Entity Paying for Your Trip:
YES NO
Are there other persons travelling with you?

Have you ever been in the U.S.?

Have you ever been issued a U.S. Visa?

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 YES NO
Have you ever been refused a U.S. Visa, or been
refused admission to the United States or
withdrawn your application for admission
at the point of entry?

Has anyone ever filed an immigrant petition on

your behalf with the United States and Immigration
Services?

Address and Phone Information:

Home Address:
Street Address:
City:
State/Province:
Postal Code:
Country:
Is your mailing address same as your Home Address? YES NO
Phone Numbers and Email Address:
Primary Phone Number:
Secondary Phone Number:
Work Phone Number (if any ):
Have you ever used any other phone numbers in the
last five years? YES NO
Email Address:
Have you ever used any other email addresses
for the last five years? YES NO

Social Media:
Please provide the social media platform you have used within the last five years and your username. Please do not
provide your passwords. Please put N/A if not applicable. (e.g., Social Media: Facebook -User Name: Britney Spears)
Social Media Provider 1: Social Media Provider 3:
User Name: User Name:

Social Media Provider 2: Social Media Provider 4:

User Name: User Name:
Do you wish to provide information about your presence on any other websites YES NO
or applications you have used within the the last five years to create or share
content (photos, videos, status updates, etc.)?
Passport Information:
Passport Number: Issuance Date (dd/mmm/yyyy):
Country if Issuance: Expiration Date (dd/mmm/yyyy):
City: Have you ever lost a passport or
State/Province: had one stolen? YES NO
Country:
U.S Point of Contract Information (Contact Person or Organization in the United States).
Surname:
Given Name:
Organization Name:
Relationship to You:

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 Family Information: Relatives
Father's Information:
Surname:
Given Name:
Date of Birth (dd/mmm/yyyy):
Is your father still living?: YES NO
Street Address:
City:
State/Province:
Postal Code:
Country:
Is your father in the U.S.? YES NO
Mother's Information:
Surname:
Given Name:
Date of Birth (dd/mmm/yyyy):
Is your father still living?: YES NO
Street Address:
City:
State/Province:
Postal Code:
Country:
Is your father in the U.S.? YES NO
YES NO
Do you have any immediate relatives, not including parents in the United States?
Do you have any other relatives in the United States?
Family Information: Fiancé/Fiancée
Fiancé/Fiancée Surname:
Fiancé/Fiancée Given Name:
Fiancé/Fiancée Date of Birth (dd/mmm/yyyy):
Fiancé/Fiancée Address:
Street Address:
City:
State/Province:
Postal Code:
Fiancé/Fiancée Occupation:
Family Information: Former Spouse
(Put N/A if not Applicable)
Do you have any former spouses? YES NO

Former Spouse Information 1 (if any):

Surname:
Given Name:
Date of Birth (dd/mmm/yyyy):
Nationality:
Former Spouse Place of Birth:
City:
Country:
Date of Marriage (dd/mmm/yyyy):
Date of Marriage Ended (dd/mmm/yyyy):

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How the Marriage Ended:

Country of Marriage Termination:

Family Information: Children
Do you have any children? YES NO
Number of Children:
Child 1 (if any):
Surname:
Given Name:
Date of Birth (dd/mmm/yyyy):
City:
State/Province:
Country:
Is this child traveling to the United States with you? YES NO
Child 2 (if any):
Surname:
Given Name:
Date of Birth (dd/mmm/yyyy):
City:
State/Province:
Country:
Is this child traveling to the United States with you? YES NO
Child 3 (if any):
Surname:
Given Name:
Date of Birth (dd/mmm/yyyy):
City:
State/Province:
Country:
Is this child traveling to the United States with you? YES NO
Current and Previous Employment
Primary Occupation: Employed Not Employed Retired
Primary Employer/Employment Information (if any):
Employer Name:
Address:
City:
State/Province:
Postal Code:
Country:
Telephone Number:
Job Title:
Employment Date From (dd/mmm/yyyy):
Employment Date To (dd/mmm/yyyy):
Brief Description of your duties:
Were you previously employed? YES NO
Previous Employer/Employment Information (if any):
Employer Name:
Address:
City:
State/Province:

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Postal Code:
Country:
Telephone Number:
Job Title:
Employment Date From (dd/mmm/yyyy):
Employment Date To (dd/mmm/yyyy):
Brief Description of your duties:
Have you attended any educational institutions at a secondary level or above? YES NO
Education or Training
Have you attended any educational institutions at a secondary level or above? YES NO
Name of Institution
Street Address:
City:
State/Province:
Postal/ZipCode:
Country:
Course of Study
Date Attendance From (mm/dd/yyyy):
Date Attendance To (mm/dd/yyyy):
Additional Information
Do you belong to a clan or tribe? YES NO
Provide a List of Languages You Speak:

YES NO
Have you traveled to any countries/regions within the last five years?

Have you belonged to, contributed to, or worked for any professional, social, or
charitable organization?

Do you have any specialized skills or training, such as firearms, explosives,

nuclear, biological, or chemical experience?

Have you served in the military?

Have you ever served in, been a member of, or been involved with a paramilitary
unit, vigilante unit, rebel group, guerille group or insurgent organization?

Security and Background:

YES NO
Do you have a communicable disease of public health significance?
(Communicable diseases of public significance include chancroid, gonorrhea,
granuloma inguinale, infectious leprosy, lymphogranuloma, venereum, infectious
stage syphilis, active tuberculosis, and others diseases as determined by the
Department of Health and Human Services.)

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?

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 YES NO
Are you or have you ever been a drug abuser or addict?

Do you have documentation to establish that you have received vaccinations in

accordance with U.S law?

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?

Have you ever committed or conspired to commit a human trafficking offense in

the United States or outside the United States?

Have you knowingly aided, abetted, assisted or colluded with an individual who
has committed or conspired to commit a severe human trafficking offense in the
United States or outside the United States?

Are you the spouse, son, or daughter of an individual who has committed or
conspired to commit a human trafficking offense in the United States or outside
the United States and have you within the last five years, knowingly benefited
from the trafficking activities?

Are you the spouse, son, or daughter of an individual who has been identified by
the president of the United States as person who plays significant role in a severe
form of trafficking in persons and have, withing the last five years, knowingly
benefited from the traficking activities?

Are you the spouse, son, or daughter of an individual who has violated any
controlled substance trafficking law, and have knowingly benefited from the
trafficking activities in the past five years?

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
enggaged 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?

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 YES NO
Are you the spouse, son, or daughter of an individual who has engaged in terrorist
activity, including providing financial assistance or other support to terrorists or
terrorist organizations, in the last five years?

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 ever engaged in the recruitment or the use of the child soldiers?

Have you, while serving as a government official, been responsible for or directly
carried out, at any time, particularly severe violations of religious freedom?

Are you a member of or affiliated with the Communist or other totalitarian party?

Have you ever directly or indirectly assited or supported any of the groups in
Colombia known as the Revolutionary Armed Forces of Colombia (FARC),
National Liberation Army (ELN), or United Self-Defense Forces of Colombia (AUC)?

Have you every through abuse of governmental or political position converted for
personal gain, confiscated or expropriated property in a foreign nation to which a
United State national had claim of ownership?

Are you the spouse, minor child, or agent of an individual who has through abuse
of governmental or political position converted for a personal gain, confiscated,
or expropriated property in a foreign nation to which a United States national had
claim of ownership?

Have you ever disclosed or trafficked in confidential U.S. business information

obtained in connection with U.S. participation in the Chemical Weapon
Convention?

Are you the spouse, minor child, or agent of an individual who has disclosed or
trafficked in confidential U.S. business information obtained in connection with
U.S. participation in the Chemical Weapon Convention?

Have you ever been directly involved in the establishment or enforcement of the
population controls forcing a woman to undergo an abortion against her free
choice or a man or a woman to undergo sterilization against his or her free will?

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 YES NO
Have you ever been directly involved in the coercive transplantation of human
organs or bodily tissue?

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?

Are you subject to a civil penalty under INA 274C?

Have you been ordered removed from the U.S. during the last five years?

Have you been ordered removed from the U.S. for a second time within the last
20 years?

Have you ever been unlawfully present and ordered removed from the U.S.
during the last ten years?

Have you ever been convicted of an aggravated felony and been ordered
removed from the U.S.?

Have you ever been unlawfully present and ordered removed from the U.S. for
more than 180 days (but no more than one year) and have voluntarily departed in
the U.S. within the last three years?

Have you ever been unlawfully present and ordered removed from the U.S. for
more than one year in the aggregate at any time during the past ten years?

Have you ever been removed or deported from any country?

Have you ever withheld custody of a U.S. citizen 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 any law or regulation?

Have you ever renounced United States citizenship for the purpose of avoiding
taxation?

Are you a former exchange visitor (J) who has not yet fulfilled the two-year
foreign residence requirement?

Do you seek to enter the United States for purpose of performing skilled or
unskilled labor but have not yet been certified by the Secretary of Labor?

Are you a graduate of a foreign medical school seeking to perform medical

services in the United States but have not yet passed the National Board of
Medical Examiners examinations or its equivalent?

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 YES NO
Are you a healthcare worker seeking to perform such work in the United States
but have not yet received certification from the Commission on Graduates of
Foreign Nursing Schools or from an equivalent approved independent
credentialing organization?

Are you permanently ineligible for U.S. citizenship?

Have you ever departed the United States in order to evade military service
during a time of war?

Are you coming to the U.S. to practice polygamy?

Has the Secretary of Homeland Security of the United States ever determined
that you knowingly made a frivolous application for asylum?

Note:

Please take your Time in filling in the Questionnaire. Information MUST be Accurate and Correct. Please review before
finalizing. All inputs will be exactly written and listed on the Government Forms.

CERTIFICATION:
This is to certify that all the details I have provided on this questionnaire sheet are correct, updated and most current
information as of date and true to the best of my knowledge and belief.

Name of the Beneficiary

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