29/10/2010 Consular Electronic Application Center -…

Nonimmigrant Visa Application

Application - Sensitive But Unclassified(SBU)

Photo Provided:

C onfirmation Number:

Personal, Address, Phone, and Passport Information

Name Provided: SANC HEZ GUDINO , C AROL JOSEFINA
Full Name in Native Language: C AROL JOSEFINA SANC HEZ GUDINO
Other Names Used: NO
Sex: FEMALE
Marital Status: MARRIED
Date of Birth: 21 JUNE 1978
Place of Birth: C ORO , FALC ON , VENEZUELA
Nationality: VENEZUELA
Other Nationalities: NO
National Identification Number: 13593204
U.S. Social Security Number: DOES NOT APPLY
U.S. Taxpayer ID Number: DOES NOT APPLY
Home Address: C ONJUNTO RESIDENC IAL VILLA MARIA
C ALLE APAMATE C ASA 2
C ity: C ORO
State/Province: FALC ON
Postal Zone/ZIP C ode: 4101
C ountry: VENEZUELA
Same Mailing Address? YES
Home Phone Number: 02689894434
Work Phone Number: 02682532781
Work Fax Number: 02682532781
Mobile/C ell Phone Number: 04246254915
Email Address: caroljosef@hotmail.com
Passport Number: 002236700
Passport Book Number: DOES NOT APPLY
C ountry/Authority that Issued Passport: VENEZUELA
C ity Where Issued: C ORO
State/Province Where Issued: FALC ON
C ountry Where Issued: VENEZUELA
Issuance Date: 14 AUGUST 2007
Expiration Date: 13 AUGUST 2012
Have you ever lost a passport or had one NO
stolen?

Travel Information
Principal Applicant? YES
▲ Purpose of Your Trip to U.S.

Purpose (1) : BUSINESS/PERSONAL TRAVEL (B1, B2)

ceac.state.gov/…/printapplication.aspx?… 1/4
29/10/2010 Consular Electronic Application Center -…
Intended Date of Arrival: 20 AUGUST 2011
Intended Length of Stay in U.S.: 20 DAY(S)
Address where you will stay in the U.S: 7751 BLAC K LAKE ROAD KISSIMMEE
ORLANDO, FLORIDA 34747
Person/Entity Paying for Your Trip: OTHER PERSON
Name of Person Paying for Your Trip: C HIRINO ZARRAGA , C ARLOS AUGUSTO
Telephone: 04146845048
Email Address: cachiriza@hotmail.com
Relationship to You: SPOUSE
Is the address of the party paying for your trip YES
the same as your Home or Mailing Address?
YES
▲ Other Persons Traveling with You:
Are you traveling as part of a group or NO
organization?
Persons Traveling with You:
Name (1) : C HIRINO ZARRAGA , C ARLOS AUGUSTO
Relationship to You: SPOUSE
Name (2) : C HIRINO SANC HEZ , C ARLOS LUIS
Relationship to You: C HILD
YES
▲ Have you ever been in the U.S.?

Previous U.S. Visits in the last 5 years:

Travel Date of Arrival (1) : 01 JULY 2008
Length of Stay: 21 DAY(S)
Do you or did you hold a U.S. Driver's License? NO
YES
▲ Have you ever been issued a U.S. Visa?

Date Last Visa was Issued: 05 JUNE 2009

Visa Number: 56014788
Are you applying for the same type of visa? YES
Are you applying in the same country where YES
the visa above is issued and is this country
your principal country of residence?
Have you been ten-printed? YES
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, been NO
refused admission to the United States, or
withdrawn your application for admission at the
point of entry?

U.S. Contact Information

C ontact Person Name in the U.S.: HOTEL, HOTEL
Organization Name in the U.S.: HOTEL
Relationship to You: OTHER
U.S. C ontact Address: HOTEL
HOTEL
ORLANDO, FLORIDA 34747
Phone Number: (800)230-4134
Email Address: DOES NOT APPLY

Family Information
Father's Surnames: SANC HEZ QUINTERO
Father's Given Names: REINALDO ANTONIO
Father's Date of Birth: 02 JANUARY 1942
Is your father in the U.S.? NO
Mother's Surnames: GUDINO DE SANC HEZ
Mother's Given Names: FANNY JOSEFINA
Mother's Date of Birth: 07 NOVEMBER 1957
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?
Spouse's Full Name: C HIRINO ZARRAGA , C ARLOS AUGUSTO

ceac.state.gov/…/printapplication.aspx?… 2/4
29/10/2010 Consular Electronic Application Center -…
Spouse's Date of Birth: 06 SEPTEMBER 1974
Spouse's Nationality: VENEZUELA
Spouse's C ity of Birth: C ORO
Spouse's C ountry of Birth: VENEZUELA
Spouse’s Address: SAME AS HOME ADDRESS

Work / Education / Training Information

Primary Occupation: OTHER
Specify Other: LIC ENC IADA EN ADMINISTRAC ION
Present Employer or School Name: ARQUIPROYEC
Address: AVENIDA LOS MEDANOS C ENTRO C OMERC IAL
LAS TEJAS LOC AL 2
C ity: C ORO
State/Province: FALC ON
Postal Zone/Zip C ode: 4101
C ountry: VENEZUELA
Month Salary in Local C urrency: 5,000
Briefly Describe your Duties: ADMINISTRADORA DE OBRAS

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 NO
any 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 NO
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 NO
to 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 NO
while 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 NO
terrorist 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 NO
official, been responsible for or directly carried
out, at any time, particularly severe violations of
religious freedom?
Have you ever been the subject of a removal or NO
deportation hearing?
Have you ever sought to obtain or assist others NO
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 failed to attend a hearing on NO
removability or inadmissibility within the last five
years?
ceac.state.gov/…/printapplication.aspx?… 3/4
29/10/2010 Consular Electronic Application Center -…
Have you ever been unlawfully present, NO
overstayed the amount of time granted by an
immigration official or otherwise violated the
terms of a U.S. visa?
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 NO
of any law or regulation?
Have you ever renounced United States NO
citizenship for the purpose of avoiding taxation?
Have you attended a public elementary school NO
on student (F) status or a public secondary
school after November 30, 1996 without
reimbursing the school?

Location Information
C urrent Location: C ARAC AS, VENEZUELA
Preparer of Application:
Did anyone assist you in filling out this NO
application?

ceac.state.gov/…/printapplication.aspx?… 4/4