21-B Rufino Pacific Tower, 6784 Ayala Ave, Makati City, Philippines 1200 Philippines Tel: (+63) 2-750-0631 2-750- 0631 ∙ (+63) 2-7502 -750-0634 0634 ∙ Mobile: (+63) 917 -9258893 www.carpolaw.com
Form DS-160 Questionnaire Personal, Address, Phone, and Passport Information Name: (Surnames)
(Given names)
Full Name in Native Language: Other Names Used (maiden, religious, professional, alias, etc.: Present Home Address: Sex:
Marital Status:
Nationality:
Other Nationalities:
National Identification Number: U.S. Social Security Number: U.S. Taxpayer ID Number: Phone Number: Email Address: Have you ever lost a passport or had one stolen? Passport Number of the stolen Passport: Country Issued Passport/Travel Document: Explain circumstances of the stolen passport: Complete Address where you will stay in the United States:
U.S. Contact Information Contact Person Name in the U.S.: Relationship to You: U.S. Contact Address: Phone Number: Email Address:
Work / Education / Training Information Primary Occupation: Present Employer or School Name: Address: 1
Month Salary in Local Currency: Describe your Duties: Previous Employment Previous Employer Name (1): Previous Supervisor’s Name: Employer’s Address:
Contact Number: Job Title: Employment Date: from:
to:
Previous Employer Name (2): Previous Supervisor’s Name: Employer’s Address:
Contact Number: Job Title: Employment Date: from:
to:
Have you traveled to any countries within the last five years?
Yes_____
No_____
Country: Have you belonged to, contributed to, or wo rked for any professional, social, or charitable organization? Yes_____
No____
Organization Name: Do you have any specialized skills or training, such as firearms, explosives, nuclear, biological, or chemical experience?
Yes_____
No_____
Yes_____
No_____
Explain: Have you ever served in the military? Name of Country:
Branch of Service:
Rank/Position:
Military Specialty:
Date of Service: from:
to:
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?
Yes_____
No_____
Explain:
Security and Background Information
Do you have a communicable disease of public health significance such as TUBERCOLOSIS, GONORRHEA, INFECTIOUS LEPROSY or OTHERS?
Yes_____
No_____
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?
Yes_____
No_____
Are you or have you ever been a drug abuser or addict? Yes_____
No_____
Do you have documentation to establish that you have received vaccinations in accordance with U.S. law?
Yes_____
2
No_____
Have you ever been arrested or convicted for any offense or crime, even though subject of a pardon, amnesty, or other similar action?
Yes_____
Have you ever violated, or engaged in a conspiracy to violate, any law relating to controlled substances?
No_____
Yes_____
No_____
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? Yes_____
Have you ever been involved in, or do you see k to engage in, money laundering? Yes_____
No_____
Have you ever committed or conspired to commit a human trafficking offense in the United States or outside the United States?
No_____
Yes_____
No_____
Have you ever knowingly aided, abetted, assisted or colluded with an individual who has committed, or conspired to commit a severe human trafficking offense in the United States or outside the United States?
Yes_____
No_____
Are you the spouse, son, or daughter of an individual who has committed or conspired to commit a human trafficking offense in the United States or outside the United States and have you within the last five years, knowingly benefited from the trafficking activities? Yes_____
No_____
Are you the spouse, son or daughter of an individual who has been identified by the President of the United States as person who plays a significant role in a severe form of trafficking in persons and have you, within the last five years, knowingly benefited from the trafficking activities? Yes_____
No_____
Are you the spouse, son or daughter of an individual who has violated any controlled substance trafficking law, and have knowingly benefited from the trafficking activities in the past five years?
Yes_____
Do you seek to engage in espionage, sabotage, export control violations, or any other illegal activity while in the United States?
Yes_____
No_____
Do you seek to engage in terrorist activities while in the United States or have you ever engaged in terrorist activities?
No_____
Yes_____
No_____
Have you ever or do you intend to provide financial assistance or other support to terrorists or terrorist organizations?
Yes_____
No_____
Are you a member or representative of a terrorist organization? Yes_____
Have you ever ordered, incited, committed, assisted, or otherwise participated in genocide? Yes_____
No_____
No_____
Have you ever committed, ordered, incited, assisted, or otherwise participated in torture?
Have you committed, ordered, incited, assisted, or otherwise participated in extrajudicial killings, political killings, or other acts of violence?
Yes_____
No_____
Have you ever engaged in the recruitment or the use of child soldiers? Yes_____
Have you, while serving as a government official, been responsible for or directly carried out, at any time, particularly severe violations of religious freedom?
Yes_____
No_____
Are you a member of or affiliated with the Communist or other totalitarian party? 3
No_____
Yes_____
No_____
Have you ever directly or indirectly assisted or supported any of the groups in Colombia known as the Revolutionary Armed Forces of Colombia (FARC), National Liberation Army (ELN), or United Self-Defense Forces of Colombia (AUC)?
Yes_____
No_____
Have you ever through abuse of governmental or political position converted for personal gain, confiscated or expropriated property in a foreign nation to which a United States national had claim of ownership?
Yes_____
No_____
Have you ever disclosed or trafficked in confidential U.S. business information obtained in connection with U.S. participation in the Chemical Weapons Convention? Yes_____
No_____
Are you the spouse, minor child, or agent of an individual who has disclosed or trafficked in confidential U.S. business information obtained in connection with U.S. participation in the Chemical Weapons Convention?
Yes_____
No_____
Have you ever been directly involved in the establishment or enforcement of population controls forcing a woman to undergo an abortion against her free choice or a man or a woman to undergo sterilization against his or her free will?
No_____
Have you ever been directly involved in the coercive transplantation of human organs or bodily tissue?
Yes_____ Yes_____
No_____
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?
Yes_____
No_____
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?
Yes_____
No_____
Have you voted in the United States in violation of any law or regulation? Yes_____
Have you ever renounced United States citizenship for the purpose of avoiding taxation? Yes_____
No_____
No_____
If you answered “yes” to any of the questions above, please explain your answer in this space.
_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
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