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Nonimmigrant Visa Application

Application - Sensitive But Unclassified(SBU)

Photo Provided:

SAMPLE - IMMIHELP.COM

Confirmation Number:

Personal, Address, Phone, and Passport Information

Name Provided: GUPTA , RAMESH
Full Name in Native Language: DOES NOT APPLY
▲ Other Names Used: YES

Other Name (1) : NONE , RAMESHBHAI

Sex: MALE
Marital Status: MARRIED
Date of Birth: 01 JANUARY 1945
Place of Birth: MUMBAI , MAHARASHTRA , INDIA
Nationality: INDIA
Other Nationalities: NO
National Identification Number: DOES NOT APPLY
U.S. Social Security Number: DOES NOT APPLY
U.S. Taxpayer ID Number: DOES NOT APPLY
Home Address: 34 SHANKAR LANE
City: BORIVALI
State/Province: MAHARASHTRA
Postal Zone/ZIP Code: 400034
Country: INDIA
Same Mailing Address? YES
Home Phone Number: 91-22-5555-1111
Work Phone Number: 91-22-5555-1111
Work Fax Number: 91-22-5555-1111
Mobile/Cell Phone Number: 91-22-5555-1111
Email Address: suresh@yahoo.com
Passport Number: A9783434
Passport Book Number: DOES NOT APPLY
Country/Authority that Issued Passport: INDIA
City Where Issued: MUMBAI
State/Province Where Issued: MAHARASHTRA
Country Where Issued: INDIA
Issuance Date: 10 JANUARY 2009
Expiration Date: 28 JANUARY 2019
Have you ever lost a passport or had one stolen? NO
Travel Information
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Principal Applicant? YES

▲ Purpose of Your Trip to U.S.
Purpose (1) : TOURIST/PERSONAL TRAVEL VISITOR (B2)
Intended Date of Arrival: 29 JUNE 2010
Intended Length of Stay in U.S.: 6 MONTH(S)
Address where you will stay in the U.S: 123 PARK AVENUE
EDISON, NEW JERSEY 08817
Person/Entity Paying for Your Trip: OTHER PERSON
Name of Person Paying for Your Trip: GUPTA , RAHUL
Telephone: 732-555-1212
Email Address: rahul@yahoo.com
Relationship to You: CHILD
Is the address of the party paying for your trip the NO
same as your Home or Mailing Address?
Paying Address: 123 PARK AVENUE
City: EDISON
State/Province: NJ
Postal Zone/ZIP Code: 08817
Country: UNITED STATES OF AMERICA
▲ Other Persons Traveling with You: YES

Are you traveling as part of a group or NO

organization?
Persons Traveling with You:
Name (1) : GUPTA , RAMILA
Relationship to You: SPOUSE
Have you ever been in the U.S.? NO
Have you ever been issued a U.S. visa? NO
Have you ever been refused a U.S. Visa, been NO
refused admission to the United States, or
withdrawn your application for admission at the
point of entry?
U.S. Contact Information
Contact Person Name in the U.S.: GUPTA, RAHUL
Organization Name in the U.S.: DO NOT KNOW
Relationship to You: RELATIVE
U.S. Contact Address: 123 PARK AVENUE
EDISON, NEW JERSEY 08817
Phone Number: (732)555-1212
Email Address: rahul@yahoo.com
Family Information
Father's Surnames: GUPTA
Father's Given Names: AMRIT
Father's Date of Birth: 10 JANUARY 1933
Is your father in the U.S.? NO
Mother's Surnames: GUPTA
Mother's Given Names: SAVITA
Mother's Date of Birth: 10 FEBRUARY 1934
Is your mother in the U.S.? NO
▲ Do you have any immediate relatives, not YES

including parents in the U.S.?

Relative Name (1) : GUPTA , RAHUL
Relationship to you: CHILD
Status: U.S. CITIZEN
Spouse's Full Name: GUPTA , RAMILA
Spouse's Date of Birth: 29 MARCH 1947
Spouse's Nationality: INDIA
Spouse's City of Birth: DELHI
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Spouse's Country of Birth: INDIA

Spouse’s Address: SAME AS HOME ADDRESS
Work / Education / Training Information
Primary Occupation: BUSINESS
Present Employer or School Name: STAR BAZAAR
Address: 2345 KHAR LANE
City: MUMBAI
State/Province: MAHARASHTRA
Postal Zone/Zip Code: 400011
Country: INDIA
Month Salary in Local Currency: 45,000
Briefly Describe your Duties: SALESMAN
Security and Background Information
Do you have a communicable disease of public NO
health significance such as tuberculosis (TB)?
Do you have a mental or physical disorder that NO
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 NO
addict?
Have you ever been arrested or convicted for any NO
offense or crime, even though subject of a
pardon, amnesty, or other similar action?
Have you ever violated, or engaged in a NO
conspiracy to violate, any law relating to
controlled substances?
Are you coming to the United States to engage in NO
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 NO
engage in, money laundering?
Do you seek to engage in espionage, sabotage, NO
export control violations, or any other illegal
activity while in the United States?
Do you seek to engage in terrorist activities while NO
in the United States or have you ever engaged in
terrorist activities?
Have you ever or do you intend to provide NO
financial assistance or other support to terrorists
or terrorist organizations?
Are you a member or representative of a terrorist NO
organization?
Have you ever ordered, incited, committed, NO
assisted, or otherwise participated in genocide?
Have you ever committed, ordered, incited, NO
assisted, or otherwise participated in torture?
Have you committed, ordered, incited, assisted, NO
or otherwise participated in extrajudicial killings,
political killings, or other acts of violence?
Have you, while serving as a government official, NO
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 NO
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 NO
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 NO
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any law or regulation?

Have you ever renounced United States NO
citizenship for the purpose of avoiding taxation?
Location Information
Current Location: 080%$,,1',$
Preparer of Application:
Did anyone assist you in filling out this NO
application?