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U.S. Embassy or Consulate where visa application was filed: Embajada Americana de Honduras
Type of Application Filed: umanitarian visa (Business & Tourism) Date Application was Filed: February 24, 2020
Confirmation #: AA009NEEM1 Date Interview is Scheduled: February 26, 2020
If this inquiry is regarding a temporary work visa, please provide the business information and
have the business representative sign the form:
Name:
First Middle Last
Address: City: State: Zip:
Phone #: ________________________ Email: _________________________________________________
Please answer all that apply to you. (If you answer yes to any questions, provide details on 2nd page of form.)
I certify, under penalty of perjury, that 1) I provided or authorized all the information in this privacy release and any
document submitted with it; 2) I reviewed and understand all the information contained in my privacy release and
submitted with it; and 3) all this information is complete, true and correct. I authorize Congressman Curtis and his staff
to access all records from federal, state and local governments as well as businesses or other organizations relevant to
the matter described above, to receive and review any information contained in my file and, if necessary, to forward any
pertinent correspondence sent by me regarding this matter. I understand that by requesting assistance of Congressman
Curtis and his staff I am obligated to provide true and correct information regarding my situation. Failure to disclose
all information or any deliberate attempt to mislead Congressman Curtis or his staff may result in the discontinuance of
assistance.
_____________________________________________________________ _______________________
Summary of Problem: