Us Visa App Form - New

7/28/2019 Us Visa App Form - New

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PERSONAL INFORMATION 1

1. Surnames2. Given Names

(If Your Passport Does Not Include A

Given Name, Please Enter FNU In

Given Names.)

3. Full Name In Native Alphabet4. Have you ever used other names (i.e maiden,

religious, professional, alias, etc.,)?NO

YES

5. Sex MALE6. Marital Status MARRIED

SINGLE

7. Date Of Birth (DD-MMM-YYYY)8. City Of Birth9. State/ Province Of Birth10.Country Of Birth INDIA

PERSONAL INFORMATION 2

11.Nationality INDIA12.Do You Hold/Have You Held Nationality

Other than the one you have indicated

above?

13.National Identification Number14.Us Social Security Number15.Us Taxpayer Id Number

ADDRESS AND PHONE INFORMATION

16.Home Addressa. Street Addressb. Street Address2c. Cityd. State / Provincee. Postal Zone / Zip Codef. Country


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17.Mailing address: is your mailing the same as your home address? NOa. Street address 405 4FLR CHALLMALL BUILDINGb. Street address2 NO11 THEYAGARAYA ROAD T NAGARc. City CHENNAId. State / province TAMILNADUe. Postal zone / zip code 600017f. Country INDIA

18.Home phone number19.Work phone number 91-44-4292930020.Work fax number 91-44-4292930121.Mobile/ cell phone number22.Email address

PASSPORT INFORMATION

23.Passport number24.Passport book number25.Country / authority that issued passport INDIA26.Where was the passport issued

a. Cityb. Statec. Country INDIAd. Issuance date(DD/MMM/YYYY)e. Expiration date (DD/MMM/YYYY)

27.Have you ever lost a passport or had onestolen?

NO

YES

TRAVEL INFORMATION

28. Are you the principal applicant YES29. Purpose of trip to us OTHER30. Other specify CREWMEMBER IN TRANSIT TO JOIN VESSEL31. Have you made specific travel

plans?

No

32. Intended date of arrival33. Intended length of stay in U.S. 7 Days34. Address where you will stay in the U.S

A. Street address CO NORTON LILLY INTERNATIONAL


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B. Street address2 ONE ST LOUIS CENTRE

C. City MOBILED. State / province LOUISIANAE. Postal zone / zip code 36602

35.Person/ entity paying for your trip COMPANY/ORGANIZATION36.Name of the organization paying for trip MITSUI OSK LINES MARITIME INDIA PVT LTD.,37.Telephone number 91-44-4292930038.Relationship to you EMPLOYER39.Is the address of the party paying For your

trip the same as your home Or mailing

address

YES

TRAVEL COMPANIONS INFORMATION

40.Are There Other Persons Traveling With You NOPREVIOUS U.S TRAVEL INFORMATION

41.Have you even been in the U.S.?Provide information on your last 5 U.S. visits:

a. Date of arrivalLength of stay

b. Date of arrivalLength of stay

42.Do you or did you ever hold a U.S driverslicense?

YES

NO

43.Have you ever been issued a U.S. visa YESNO

Date of last visa was issued

Visa number

44.Are you applying for the same type of visa? YES45.Are you applying in the same country where

the visa above was issued and is this country

your principal country of residence?

YES

46.Have you been ten printed NO47.Has your us visa ever been lost or stolen? NO

YES

48.Has your us visa ever been cancelled orrevoked?

NO

YES


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49.Have you even been refused a us visa, beenrefused admission to the united states, or

withdrawn your application for admission at

the point of entry?

NO

YES

U S POINT OF CONTACT INFORMATION

50.Contact personSurnames

Given names

51.Organization name in the U.S. CO NORTON LILLY INTERNATIONAL52.Relationship to you BUSINESS ASSOCIATE53.Address and phone number of point of contact

street address ONE ST LOUIS CENTRE

City MOBLE

State LOUISIANA

Zip code 36602

Phone number 251- 219-3270

E mail address

FAMILY INFORMATION:

54.Fathers full name and date of birthSurnames

Given names

Date of birth

Is your father in the U.S? YES

NO

55.Mothers full name and date of birthSurnames

Given names

Date of birth

Is your father in the U.S? YES

NO

56.Do you have any immediate relatives, notincluding parents in the United States?

NO

YES

57.Do you have any other relatives in theunited states?

NO

YES


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58.Spouses full name and date of birthSurnames

Given names

Date of birth

Nationality

City of Birth

Country of Birth

Address SAME AS MAILING ADDRESS

WORK/ EDUCATION / TRAINING INFORMATION

59.Primary occupation OTHER60.Specify other SHIPPING61.Present employer or school name MITSUI OSK LINES MARITIME INDIA PVT LTD

a. Street address 405 4FLR CHALLMALL BUILDINGb. Street address2 NO11 THEYAGARAYA ROAD T NAGARc. City CHENNAId. State / province TAMILNADUe. Postal zone / zip code 600017f. Country INDIA

62.Month salary in local currency Rs.63.Briefly describe your duties

64.Previously employedEmployer

name

Employer

address

City State Postal

code

Country Telephone

number

Job

title

Supervis

ors

name

Emp.

Date

from

Emp. D

to


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65.Have you attended any educational institutions other than elementary schools?Name of Institution Address of

Inst.

City State Postal

code

Country Course

Study

Date OFATTENDANCE

From

DateATTEND

To

TENTH

PLUS

TWO

BE

/ BSC

PRE SEA

66.Do you belong to a clan or tribe NoYes

67.Have you traveled to any countries within the lastfive years?

68.Have you belonged to, contributed to, or worked forany professional, social, or charitable organization?

No

Yes

69.Do you have any specialized skills or training,including firearms, explosives, nuclear, biological, or

chemical experience?

No

Yes

70.Have you ever served in the military? No

Yes

71.Have you ever served in, been a member of, or beeninvolved with a paramilitary unit, vigilante unit, rebel

group, guerrilla group, or insurgent organization?

No

Yes

SECURITY AND BACKGROUND INFORMATION

72.Do you have a communicable disease of publichealth significance such as tuberculosis (TB)?

No

Yes

73.Do you have a mental or physical disorder that posesor is likely to pose a threat to the safety or welfare ofyourself or others?

No

Yes

74.Are you or have you ever been a drug abuser oraddict?

No

Yes

75.Have you ever been arrested or convicted for anyoffense or crime, even though subject of a pardon,

amnesty, or other similar action?

No

Yes


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76.Have you ever violated, or engaged in a conspiracy toviolate, any law relating to controlled substances?

No

Yes

77.Are you coming to the United States to engage inprostitution or unlawful commercialized vice or have

you been engaged in prostitution or procuring

prostitutes within the past 10 years?

No

Yes

78.Have you ever been involved in, or do you seek toengage in, money laundering?

No

Yes

79.Do you seek to engage in espionage, sabotage,export control violations, or any other illegal activity

while in the United States?

No

Yes

80.Do you seek to engage in terrorist activities while inthe United States or have you ever engaged in

terrorist activities?

No

Yes

81.Have you ever or do you intend to provide financialassistance or other support to terrorists or terrorist

organizations?

No

Yes

82.Are you a member or representative of a terroristorganization?

No

Yes

83.Have you ever ordered, incited, committed, assisted,or otherwise participated in genocide?

No

Yes

84.Have you ever committed, ordered, incited, assisted,or otherwise participated in torture?

No

Yes

85.Have you committed, ordered, incited, assisted, orotherwise participated in extrajudicial killings,

political killings, or other acts of violence?

No

Yes

86.Have you, while serving as a government official,been responsible for or directly carried out, at any

time, particularly severe violations of religious

freedom?

No

Yes

87.Have you ever been the subject of a removal ordeportation hearing?

No

Yes

88.Have you ever sought to obtain or assist others toobtain a visa, entry into the United States, or any

other United States immigration benefit by fraud or

willful misrepresentation or other unlawful means?

No

Yes

89.Have you ever been unlawfully present, overstayedthe amount of time granted by an immigration

official or otherwise violated the terms of a U.S. visa?

No

Yes

90.Have you ever withheld custody of a U.S. citizen childoutside the United States from a person granted legal

custody by a U.S. court?

No

Yes


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d. Street address 405 4FLR CHALLMALL BUILDINGe. Street address2 NO11 THEYAGARAYA ROAD T NAGARf. City CHENNAIg. State / province TAMILNADUh. Postal zone / zip code 600017i. Country INDIAj. Telephone number 91-44-42929300

98. Are you serving aboard a seagoing ship or vessel?a. Seagoing Ship/Vessel Name:b. Seagoing Ship/Vessel Identification

Number:

99.LOCATION INFORMATIONa. Current Location:

100. Preparer of Applicationa. Did anyone assist you in filling out this

application?

NO

91. Have you voted in the United States in violation ofany law or regulation?

No

Yes

92.Have you ever renounced United States citizenshipfor the purpose of avoiding taxation?

No

Yes

93. Have you attended a public elementary school onstudent (F) status or a public secondary school after

November 30, 1996 without reimbursing the school?

No

Yes

CREW VISA INFORMATION

94. Specific job title aboard aircraft or vessel:95.Name of company that owns the aircraft or vessel you

will be working on:

MITSUI OSK LINES MARITIME INDIA PVT LTD

96.Company telephone number: 91-44-4292930097.Did you acquire your position using a

recruiting/manning/crewing agency?

YES

a. Agency Name: MITSUI OSK LINES MARITIME INDIA PVT LTDb. Surname SRINIVASANc. Given name SATHYANARYANAN

Us Visa App Form - New

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