Nonimmigrant Visa Application

Transkripsi

1 Aplikasi Visa Nonimigran Nonimmigrant Visa Application Application - Sensitive But Unclassified(SBU) Print Application Back: Confirmation Page Photo Provided: Confirmation Number: Personal, Address, Phone, and Passport Information Name Provided: Full Name in Native Language: Other Names Used: UMEZA, SILVERA SILVERA UMEZA Sex: FEMALE Marital Status: SINGLE Date of Birth: 17 AUGUST 1945 Place of Birth: JAKARTA Nationality: Other Nationalities: National Identification Number: U.S. Social Security Number: U.S. Taxpayer ID Number: DOES T APPLY DOES T APPLY Home Address: PILIH (JIKA ALAMAT SURAT MENYURAT SAMA Same Mailing Address? DENGAN ALAMAT RUMAH) PILIH (JIKA ALAMAT SURAT MENYURAT BERBEDA DENGAN ALAMAT RUMAH) JIKA PILIH (ISI DENGAN ALAMAT SURAT MENYURAT Mailing Address: JIKA PILIH (ISI DENGAN ALAMAT SURAT MENYURAT

2 JIKA PILIH (ISI DENGAN ALAMAT SURAT MENYURAT JIKA PILIH (ISI DENGAN ALAMAT SURAT MENYURAT Home Phone Number: Work Phone Number: Work Fax Number: Mobile/Cell Phone Number: Passport Number: A Passport Book Number: DOES T APPLY Country/Authority that Issued Passport: City Where Issued: JAAKRTA SELATAN State/Province Where Issued: Country Where Issued: Issuance Date: 17 AUGUST 1965 Expiration Date: 17 AUGUST 1970 Have you ever lost a passport or had one stolen? Travel Information Principal Applicant? Purpose of Your Trip to U.S. Purpose (1) : STUDENT/EXCHANGE VISA (F, J, M, Q) Specific Travel Plan? Date of Arrival in U.S.: 12 MARCH 2011 Arrival COLORADO Date of Departure from U.S.: 7 MAY 2011 Departure COLORADO The Location you plan to visit in the U.S.: Location (1): USA Address where you will stay in the U.S: Person/Entity Paying for Your Trip: Name of Company/Organization Paying for Trip: Telephone: Relationship to You: Is the address of the party paying for your trip the same as your Home or Mailing Address? Paying Address: Other Persons Traveling with You: 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 Have you ever been refused a U.S. Visa, been refused admission to the United States, or withdrawn your application for admission at the point of entry?

3 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: Family Information Father's Surnames: KASMIAN Father's Given Names: KASMIAN Father's Date of Birth: 17 AUGUST 1900 Is your father in the U.S.? Mother's Surnames: MUSRIFAH Mother's Given Names: MUSRIFAH Mother's Date of Birth: 17 AUGUST 1910 Is your mother in the U.S.? Do you have any immediate relatives, not including parents in the U.S.? Do you have any other relatives in the United States? Work / Education / Training Information Primary Occupation: STUDENT Present Employer or School Name: UNIVERSITY OF IIEF Address: Postal Zone/Zip Code: Month Salary in Local Currency: NE Briefly Describe your Duties: NE Were you previously employed? Have you attended any educational institutions other than elementary schools? DIMULAI DARI SMP SAMPAI S1 Name of Institution (1) : SMP 000 Address of Institution: NE Date of Attendance From: 17 AUGUST 1950 Date of Attendance To: 17 AUGUST 1953 Name of Institution (1) : SMA 000 Address of Institution: NE Date of Attendance From: 17 AUGUST 1953 Date of Attendance To: 17 AUGUST 1958 Name of Institution (1) : Address of Institution: UNIVERSITY OF IIEF

4 12980 EDUCATION Date of Attendance From: 17 AUGUST 1958 Date of Attendance To: 17 AUGUST 1962 Do you belong to a clan or tribe? Have you traveled to any countries 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, including firearms, explosives, nuclear, biological, or chemical experience? Have you ever served in the military? Have you ever served in, been a member of, or been involved with a paramilitary unit, vigilante unit, rebel group, guerrilla group, or insurgent organization? 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

5 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? 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? Student/Exchange Visa Information Additional Point of Contact Information: Name(1): Telephone Number: Diisi dengan Contact Person/Referensi di Indonesia di luar keluarga (dan IIEF) misalnya: teman, dosen dll. ALamat harus jelas, lengkap dan mudah dicapai dengan petugas pos. Name(2): Telephone Number: Diisi dengan Contact Person/Referensi di Indonesia di luar keluarga (dan IIEF) misalnya: teman, dosen dll. ALamat harus jelas, lengkap dan mudah dicapai dengan petugas pos. SEVIS ID: Do you intend to study in the U.S.? Name of School: Location Information Current Location: JAKARTA,