Personal, Address, Phone, and Passport Information

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Edit Personal Information
Name &rovided: '$%%(IN, )* )$'$%'IN
+ull Name in Native (lphabet: *$,% N$T (&&-Y
$ther Names .sed: N$
Telecode Name .sed: N$
%e: )(-,
)arital %tatus: )(//I,*
*ate of Birth: 01 2.-Y 0343
5ountry6/egion of Birth: )(*(/I&./, B(N7-(*,%'
5ountry6/egion of $rigin
8Nationality9:
B(N7-(*,%'
*o you hold or have you held
any nationality other than the
one indicated above on
nationality:
N$
National Identification
Number:
0343;<0=4>1????0=
..%. %ocial %ecurity Number: *$,% N$T (&&-Y
..%. Tapayer I* Number: *$,% N$T (&&-Y
Edit Address and Phone
Information
'ome (ddress: %'I@*(/ @(N*I, &(N5'(/
%'IB5'(/
5ity: )(*(/I&./
%tate6&rovince: *$,% N$T (&&-Y
&ostal Aone6AI& 5ode: *$,% N$T (&&-Y
5ountry6/egion: B(N7-(*,%'
%ame )ailing (ddress: Y,%
&rimary &hone Number: ?0=B=0;43=3
%econdary &hone Number: *$,% N$T (&&-Y
Cor! &hone Number: ?041B==41=?
,mail (ddress: mohoshin0343Dgmail.com
Edit Passport/Travel Document Information
&assport6Travel *ocument
Type:
/,7.-(/
&assport6Travel *ocument
Number:
((>3?341<
&assport Boo! Number: *$,% N$T (&&-Y
5ountry6(uthority that Issued
&assport6Travel *ocument:
B(N7-(*,%'
5ity where issued: *'(@(
%tate6&rovince where issued: *'(@(
5ountry6/egion where issued: B(N7-(*,%'
Issuance *ate: B3 2.N, B?00
,piration *ate: B= 2.N, B?0>
'ave you ever lost a passport
or had one stolen:
Y,%
&assport6Travel *ocument
Number 809:
((3?B131B
5ountry6(uthority that
Issued &assport6Travel
*ocument:
B(N7-(*,%'
,plain:
I -$%T IT $N, %'$&&IN7
)(-- IN *'(@(,
B(N7-(*,%'. I T/Y T$
+IN* $.T )Y &(%%&$/T
(N* .N(B-, T$ +IN* $.T
(N* /,&$/T T$ -$5(-
&$-I5, %T(TI$N (N*
(&&-I,* +$/ N,C
&(%%&$/T T$ 7IV, T',
-$%T *$5.),NT%.
Travel Information
Edit Travel Information
The -ist of &urposes of Trip to the ..%.
&urpose of Trip to the ..%.
809:
T,)&. B.%IN,%% &-,(%./,
VI%IT$/ 8B9
%pecify: B.%IN,%% E T$./I%)
8T,)&$/(/Y VI%IT$/9
8B06BB9
'ave you made specific travel
plans:
N$
Intended *ate of (rrival: 1? $5T$B,/ B?0<
Intended -ength of %tay in
..%.:
0; *(Y8%9
(ddress where you will stay in
the ..%.:
1B?;0 ,(%T NIN, */
-(7.N( NI7.,-
-(7.N( NI7.,-, 5(-I+$/NI(
3B>44
&erson6,ntity &aying for Your
Trip:
%,-+
Edit Travel Companions
Information
$ther &ersons Traveling with
You:
N$
Edit Previous U.S. Travel
Information
'ave you ever been in the
..%.:
N$
'ave you ever been issued a
..%. visa:
N$
'ave you ever been refused a
..%. Visa, or been refused
admission to the .nited %tates,
or withdrawn your application
for admission at the port of
entry:
N$
'as anyone ever filed an
immigrant petition on your
behalf with the .nited %tates
5itiFenship and Immigration
%ervices:
N$
U.S. Contact Information
Edit U.S. Point of Contact Information
5ontact &erson Name in the
..%.:
&$C,--, 7,$/7, 2$%,&'
$rganiFation Name in the
..%.:
/,.%, 2,(N%
/elationship to You: B.%IN,%% (%%$5I(T,
..%. 5ontact (ddress: 1B?;0 ,(%T NIN, */
-(7.N( NI7.,-
-(7.N( NI7.,-, 5(-I+$/NI(
3B>44
&hone Number: B0<<343<11
,mail (ddress: gpowell;Daol.com
Family Information
Edit Family Information !elatives
+atherGs %urnames: '$C-(*,/
+atherGs 7iven Names: '(AI )$A(++(/
+atherGs *ate of Birth: 0? )(/5' 03;1
Is your father in the ..%.: N$
)otherGs %urnames: B,7.)
)otherGs 7iven Names: )(').*(
)otherGs *ate of Birth: ?< )(/5' 03>;
Is your mother in the ..%.: N$
*o you have any immediate
relatives, not including parents
in the ..%.:
N$
*o you have any other
relatives in the .nited %tates:
N$
Edit Family Information Spouse
%pouseGs +ull Name: B,7.), N(*I/(
%pouseGs *ate of Birth: ?; (.7.%T 033B
%pouseGs 5ountry6/egion of
$rigin 8Nationality9:
B(N7-(*,%'
%pouseGs 5ity of Birth: )(*(/I&./
%pouseGs 5ountry6/egion of B(N7-(*,%'
Birth:
%pouse#s (ddress: %(), (% '$), (**/,%%
Work / Education / Training Information
Edit Present "or#
Information
&rimary $ccupation: B.%IN,%%
&resent ,mployer or %chool
Name:
)$T',/ -(N* (%%$5I(TI$N
&resent ,mployer or %chool
(ddress:
&(N5'(/ *(-I )(/@,T
&(N5'(/, %'IB5'(/
5ity: )(*(/I&./
%tate6&rovince: *$,% N$T (&&-Y
&ostal Aone6Aip 5ode: *$,% N$T (&&-Y
5ountry6/egion: B(N7-(*,%'
Cor! &hone Number: ?0=B=0;43=3
)onthly %alary in -ocal
5urrency 8if employed9:
<?????
Briefly *escribe your *uties:
I () ( &/$&/I,T$/ $+
)$T',/ -(N* (%%$5I(TI$N
(N* $CN,/ $+ )(*(N,
7(/),NT% (N* I () (N
(*V$5(T,. I '(V, T$
&/(5TI5, (-%$ %$), TI), IN
T', 5$./T.
Edit Previous "or#
Information
Cere you previously
employed:
Y,%
,mployer Name 809:
'()I* &(5@(7IN7 (N*
5$NT(IN,/ -I)IT,*
,mployer (ddress:
@(%'I)&./ /$(*,
@$N(B(/I
7(AI&./
5ity: *'(@(
%tate6&rovince: *'(@(
&ostal Aone6Aip 5ode: *$,% N$T (&&-Y
Security and Background Information
Edit Part $
*o you have a communicable disease of public health
significance: 85ommunicable diseases of public
significance include chancroid, gonorrhea, granuloma
inguinale, infectious leprosy, lymphogranuloma venereum,
infectious stage syphilis, active tuberculosis, and other
diseases as determined by the *epartment of 'ealth and
'uman %ervices.9
N$
*o you have a mental or physical disorder that poses or is
li!ely to pose a threat to the safety or welfare of yourself
or others:
N$
(re you or have you ever been a drug abuser or addict: N$
Edit Part %
'ave you ever been arrested or convicted for any offense
or crime, even though subHect of a pardon, amnesty, or
other similar action:
N$
'ave you ever violated, or engaged in a conspiracy to
violate, any law relating to controlled substances:
N$
(re you coming to the .nited %tates to engage in
prostitution or unlawful commercialiFed vice or have you
been engaged in prostitution or procuring prostitutes
within the past 0? years:
N$
'ave you ever been involved in, or do you see! to engage
in, money laundering:
N$
'ave you ever committed or conspired to commit a
human traffic!ing offense in the .nited %tates or outside
the .nited %tates:
N$
(re you the spouse, son, or daughter of an individual who
has committed or conspired to commit a human traffic!ing
offense in the .nited %tates or outside the .nited %tates
and have you within the last five years, !nowingly
benefited from the traffic!ing activities:
N$
'ave you !nowingly aided, abetted, assisted or colluded
with an individual who has committed or conspired to
commit a severe human traffic!ing offense in the .nited
%tates or outside the .nited %tates:
N$
Edit Part &
*o you see! to engage in espionage, sabotage, eport
control violations, or any other illegal activity while in the
.nited %tates:
N$
*o you see! to engage in terrorist activities while in the
.nited %tates or have you ever engaged in terrorist
activities:
N$
'ave you ever or do you intend to provide financial
assistance or other support to terrorists or terrorist
organiFations:
N$
(re you a member or representative of a terrorist
organiFation:
N$
'ave you ever ordered, incited, committed, assisted, or
otherwise participated in genocide:
N$
'ave you ever committed, ordered, incited, assisted, or
otherwise participated in torture:
N$
'ave you committed, ordered, incited, assisted, or
otherwise participated in etraHudicial !illings, political
!illings, or other acts of violence:
N$
'ave you ever engaged in the recruitment or the use of
the child soldiers:
N$
'ave you, while serving as a government official, been
responsible for or directly carried out, at any time,
particularly severe violations of religious freedom:
N$
'ave you ever been directly involved in the establishment
or enforcement of the population controls forcing a woman
to undergo an abortion against her free choice or a man
or a woman to undergo steriliFation against his or her free
will:
N$
'ave you ever been directly involved in the coercive
transplantation of human organs or bodily tissue:
N$
Edit Part '
'ave you ever sought to obtain or assist others to obtain
a visa, entry into the .nited %tates, or any other .nited
%tates immigration benefit by fraud or willful
misrepresentation or other unlawful means:
N$
Edit Part (
'ave you ever withheld custody of a ..%. citiFen child
outside the .nited %tates from a person granted legal
custody by a ..%. court:
N$
'ave you voted in the .nited %tates in violation of any law
or regulation:
N$
'ave you ever renounced .nited %tates citiFenship for the
purpose of avoiding taation:
N$