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The document contains personal information of an individual from Indonesia, including details about their nationality, travel plans to the U.S., and previous travel history. It outlines their purpose for visiting the U.S. as a temporary visitor for business and tourism, along with information about their family and employment. Additionally, it includes questions regarding previous U.S. visa applications and any affiliations with organizations or military service.

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12 views6 pages

Questioner

The document contains personal information of an individual from Indonesia, including details about their nationality, travel plans to the U.S., and previous travel history. It outlines their purpose for visiting the U.S. as a temporary visitor for business and tourism, along with information about their family and employment. Additionally, it includes questions regarding previous U.S. visa applications and any affiliations with organizations or military service.

Uploaded by

sgxbrkx4vk
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
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Name Provided:

Full Name in Native Alphabet:

Other Names Used: NO

Telecode Name Used: NO

Sex:
Marital Status:
Date of Birth:

Country/Region of Birth: INDONESIA

Country/Region of Origin (Nationality): INDONESIA

Do you hold or have you held any nationality


other than the one indicated above on NO
nationality?

National Identification Number:

U.S. Social Security Number: DOES NOT APPLY

U.S. Taxpayer ID Number: DOES NOT APPLY

Edit Address and Phone Information

Home Address:

City:
State/Province:
Postal Zone/ZIP Code:
Country/Region:
Same Mailing Address?
Primary Phone Number:
Secondary Phone Number:
Work Phone Number:
Email Address:

Edit Passport/Travel Document Information

Passport/Travel Document Type: REGULAR


Passport/Travel Document Number:

Passport Book Number: DOES NOT APPLY

Country/Authority that Issued


INDONESIA
Passport/Travel Document:

City where issued:

Country/Region where issued:

Issuance Date:
Expiration Date:

Have you ever lost a passport or had one


NO
stolen?

The List of Purposes of Trip to the U.S.


TEMP. BUSINESS PLEASURE
Purpose of Trip to the U.S. (1):
VISITOR (B)

BUSINESS & TOURISM


Specify:
(TEMPORARY VISITOR) (B1/B2)

Have you made specific travel plans? YES

Provide a complete itinerary for your travel


to the U.S.
Date of Arrival in U.S.:
Arrival Flight:
Arrival City:
Date of Departure from U.S.:
Departure Flight:
Departure City:
The Location(s) you plan to visit in the U.S.
Location (1):

Address where you will stay in the U.S.:

Person/Entity Paying for Your Trip:

Name of Company/Organization Paying for


Trip:

Telephone Number:
Relationship to You:

Address of Company/Organization Paying:


City:
State/Province:
Postal Zone/ZIP Code:
Country/Region:

Edit Travel Companions Information

Other Persons Traveling with You: YES


Are you traveling as part of a group or
YES
organization?
Name of the Group:

Edit Previous U.S. Travel Information

Have you ever been in the U.S.?

Date Arrived (1):


Length of Stay:
Do you or did you ever hold a U.S. Driver's
NO
License?

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

Date Last Visa was Issued:


Visa Number:

Are you applying for the same type of visa? YES

Are you applying in the same country or


location where the visa above was issued,
YES
and is this country or location your place of
principal of residence?
Have you been ten-printed? NO

Has your U.S. Visa ever been lost or stolen? NO

Has your U.S. Visa ever been cancelled or


NO
revoked?

Have you ever been refused a U.S. Visa, or


been refused admission to the United States,
NO
or withdrawn your application for admission
at the port of entry?
Has anyone ever filed an immigrant petition
on your behalf with the United States NO
Citizenship and Immigration Services?

Contact Person Name in the U.S.:

Organization Name in the U.S.:

Relationship to You:

U.S. Contact Address:

Phone Number:
Email Address:
Father's Surnames:
Father's Given Names:
Father's Date of Birth:
Is your father in the U.S.?
Mother's Surnames:
Mother's Given Names:
Mother's Date of Birth:
Is your mother in the U.S.? NO

Do you have any immediate relatives, not


NO
including parents in the U.S.?

Do you have any other relatives in the United


NO
States?

Primary Occupation:

Present Employer or School Name:

Present Employer or School Address:

City:
State/Province:

Postal Zone/Zip Code:

Country/Region:

Work Phone Number:

Monthly Salary in Local Currency (if


employed):
Briefly Describe your Duties:

Edit Previous Work Information


Were you previously employed?

Have you attended any educational


institutions at a secondary level or above?

Name of Institution (1):


Address of Institution:
City:
State/Province:
Postal Zone/ZIP Code:
Country/Region:
Course of Study:
Date of Attendance From:
Date of Attendance To:
Name of Institution (2):
Address of Institution:
City:
State/Province:
Postal Zone/ZIP Code:
Country/Region:
Course of Study:
Date of Attendance From:
Date of Attendance To:
Name of Institution (3):
Address of Institution:
City:
State/Province:
Postal Zone/ZIP Code:
Country/Region:
Course of Study:
Date of Attendance From:
Date of Attendance To:

Edit Additional Information

Do you belong to a clan or tribe?

Provide a List of Languages You Speak:

Language Name: (1):


Language Name: (2):
Have you traveled to any countries within
the last five years?
Country Visited (1):
Country Visited (2):
Country Visited (3):
Country Visited (4):
Country Visited (5):
Country Visited (6):
Country Visited (7):
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?

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