13/3/2017 ConsularElectronicApplicationCenterPrintApplication

OnlineNonimmigrantVisaApplication(DS160)

ApplicationSensitiveButUnclassified(SBU)

Wedonotneedaprintedcopyofyourapplicationatanypointduringyourinterviewprocess.Onlyprintthis
applicationifyouwantacopyforyourownrecords.Ifyouprintyourapplication,pleasekeepitsecure.

PhotoProvided:

ConfirmationNumber:

YourPersonalCopyDoNotBringtoInterview
Personal,Address,Phone,andPassport/TravelDocumentInformation
NameProvided: FRIASLAUSEL,ASUNCION

FullNameinNativeLanguage: ASUNCIONFRIASLAUSEL

OtherNamesUsed: NO

TelecodeNameUsed: NO

Sex: FEMALE

MaritalStatus: SINGLE

DateofBirth: 20MAY1934

PlaceofBirth: MONTEPLATA,MONTEPLATA,DOMINICAN
REPUBLIC

Country/RegionofOrigin(Nationality): DOMINICANREPUBLIC

Doyouholdorhaveyouheldanynationalityotherthantheone NO
indicatedaboveonnationality?

Areyouapermanentresidentofacountry/regionotherthanyour NO
country/regionoforigin(nationality)above?

NationalIdentificationNumber: 00105732929

U.S.SocialSecurityNumber: DOESNOTAPPLY

U.S.TaxpayerIDNumber: DOESNOTAPPLY

HomeAddress: CALLEPRIMERACASANO219

SECTORVILLADUARTE

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City: SANTODOMINGOESTE
YourPersonalCopyDoNotBringtoInterview
State/Province: SANTODOMINGO

PostalZone/ZIPCode: DOESNOTAPPLY

Country/Region: DOMINICANREPUBLIC

SameMailingAddress? YES

PrimaryPhoneNumber: 8092736942

SecondaryPhoneNumber: 8299446904

WorkPhoneNumber: DOESNOTAPPLY

EmailAddress: asuncionfriaslausel1934@hotmail.com

Passport/TravelDocumentType: REGULAR

Passport/TravelDocumentNumber: RD4196283

PassportBookNumber: 4196283

Country/AuthoritythatIssuedPassport/TravelDocument: DOMINICANREPUBLIC

CityWhereIssued: SANTODOMINGOESTE

State/ProvinceWhereIssued: SANTODOMINGO

Country/RegionWhereIssued: DOMINICANREPUBLIC

IssuanceDate: 17OCTOBER2016

ExpirationDate: 17OCTOBER2022

Haveyoueverlostapassportorhadonestolen? NO

TravelInformation
TheListofPurposesofTriptotheU.S.

PurposeofTriptotheU.S.(1): TEMP.BUSINESSPLEASUREVISITOR
(B)

Specify: BUSINESS&TOURISM(TEMPORARY
VISITOR)(B1/B2)

IntendedDateofArrival: 10JUNE2017

IntendedLengthofStayinU.S.: 3WEEK(S)

AddresswhereyouwillstayintheU.S.: 7DELLTERRAHIDEPARK

Person/EntityPayingforYourTrip: OTHERPERSON

PersonPayingforYourTrip: PEREIRAFRIAS,RAMONANTONIO

TelephoneNumber: 6178391784

EmailAddress: antonioramon02pereyra@gmail.com

RelationshiptoYou: CHILD

Istheaddressofthepartypayingforyourtripthesameasyour NO
HomeorMailingAddress?

Payer'sAddress: 7DELL
TERRAHIDE
PARK

City: BOSTON

State/Province: MASSACHUSETTS

PostalZone/ZIPCode: 02136

Country/Region: UNITEDSTATESOFAMERICA

Arethereotherpersonstravelingwithyou? YES

Areyoutravelingaspartofagroupororganization? NO

PersonsTravelingwithYou:

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Name(1):
YourPersonalCopyDoNotBringtoInterview
PEREYRAFRIAS,RAMONANTONIO

RelationshiptoYou: CHILD

HaveyoueverbeenintheU.S.? NO

HaveyoueverbeenissuedaU.S.visa? NO

HaveyoueverbeenrefusedaU.S.Visa,orbeenrefusedadmission NO
totheUnitedStates,orwithdrawnyourapplicationforadmissionat
theportofentry?

Hasanyoneeverfiledanimmigrantpetitiononyourbehalfwiththe NO
UnitedStatesCitizenshipandImmigrationServices?

U.S.ContactInformation
ContactPersonNameintheU.S.: PEREYRAFRIAS,RAMONANTONIO

OrganizationNameintheU.S.: DONOTKNOW

RelationshiptoYou: RELATIVE

U.S.ContactAddress: 7DELLTERRAHIDEPARK

BOSTON,MASSACHUSETTS02136

PhoneNumber: 6178391789

EmailAddress: antonioramon02pereyra@gmail.com

FamilyInformation
Father'sSurnames: FRIAS

Father'sGivenNames: TOMAS

Father'sDateofBirth: 14AUGUST1904

IsyourfatherintheU.S.? NO

Mother'sSurnames: LAUSEL

Mother'sGivenNames: ISABEL

Mother'sDateofBirth: 23JANUARY1906

IsyourmotherintheU.S.? NO

Doyouhaveanyimmediaterelatives,notincludingparentsinthe YES
U.S.?

RelativeName(1): PEREYRAFRIAS,RAMONANTONIO

Relationshiptoyou: CHILD

Status: U.S.CITIZEN

RelativeName(2): OBJIOFRIAS,JORGE

Relationshiptoyou: CHILD

Status: U.S.LEGALPERMANENTRESIDENT(LPR)

Work/Education/TrainingInformation
PrimaryOccupation: HOMEMAKER

Wereyoupreviouslyemployed? NO

SecurityandBackgroundInformation
Doyouhaveacommunicablediseaseofpublichealthsignificance?(Communicablediseasesofpublic NO
significanceincludechancroid,gonorrhea,granulomainguinale,infectiousleprosy,lymphogranuloma
venereum,infectiousstagesyphilis,activetuberculosis,andothersdiseasesasdeterminedbytheDepartment
ofHealthandHumanServices.)

Doyouhaveamentalorphysicaldisorderthatposesorislikelytoposeathreattothesafetyorwelfareof NO
yourselforothers?

Areyouorhaveyoueverbeenadrugabuseroraddict? NO

Haveyoueverbeenarrestedorconvictedforanyoffenseorcrime,eventhoughsubjectofapardon,amnesty, NO
orothersimilaraction?

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Haveyoueverviolated,orengagedinaconspiracytoviolate,anylawrelatingtocontrolledsubstances? NO
YourPersonalCopyDoNotBringtoInterview
AreyoucomingtotheUnitedStatestoengageinprostitutionorunlawfulcommercializedviceorhaveyou NO
beenengagedinprostitutionorprocuringprostituteswithinthepast10years?

Haveyoueverbeeninvolvedin,ordoyouseektoengagein,moneylaundering? NO

HaveyouevercommittedorconspiredtocommitahumantraffickingoffenseintheUnitedStatesoroutside NO
theUnitedStates?

Areyouthespouse,son,ordaughterofanindividualwhohascommittedorconspiredtocommitahuman NO
traffickingoffenseintheUnitedStatesoroutsidetheUnitedStatesandhaveyouwithinthelastfiveyears,
knowinglybenefitedfromthetraffickingactivities?

Haveyouknowinglyaided,abetted,assistedorcolludedwithanindividualwhohascommittedorconspiredto NO
commitaseverehumantraffickingoffenseintheUnitedStatesoroutsidetheUnitedStates?

Doyouseektoengageinespionage,sabotage,exportcontrolviolations,oranyotherillegalactivitywhilein NO
theUnitedStates?

DoyouseektoengageinterroristactivitieswhileintheUnitedStatesorhaveyoueverengagedinterrorist NO
activities?

Haveyoueverordoyouintendtoprovidefinancialassistanceorothersupporttoterroristsorterrorist NO
organizations?

Areyouamemberorrepresentativeofaterroristorganization? NO

Haveyoueverordered,incited,committed,assisted,orotherwiseparticipatedingenocide? NO

Haveyouevercommitted,ordered,incited,assisted,orotherwiseparticipatedintorture? NO

Haveyoucommitted,ordered,incited,assisted,orotherwiseparticipatedinextrajudicialkillings,political NO
killings,orotheractsofviolence?

Haveyoueverengagedintherecruitmentortheuseofthechildsoldiers? NO

Haveyou,whileservingasagovernmentofficial,beenresponsibleforordirectlycarriedout,atanytime, NO
particularlysevereviolationsofreligiousfreedom?

Haveyoueverbeendirectlyinvolvedintheestablishmentorenforcementofthepopulationcontrolsforcinga NO
womantoundergoanabortionagainstherfreechoiceoramanorawomantoundergosterilizationagainsthis
orherfreewill?

Haveyoueverbeendirectlyinvolvedinthecoercivetransplantationofhumanorgansorbodilytissue? NO

Haveyoueversoughttoobtainorassistotherstoobtainavisa,entryintotheUnitedStates,oranyother NO
UnitedStatesimmigrationbenefitbyfraudorwillfulmisrepresentationorotherunlawfulmeans?

HaveyoueverwithheldcustodyofaU.S.citizenchildoutsidetheUnitedStatesfromapersongrantedlegal NO
custodybyaU.S.court?

HaveyouvotedintheUnitedStatesinviolationofanylaworregulation? NO

HaveyoueverrenouncedUnitedStatescitizenshipforthepurposeofavoidingtaxation? NO

LocationInformation
Locationwhereyouwillbesubmittingyourapplication

CurrentLocation: SANTODOMINGO,DOMINICANREPUBLIC

PreparerofApplication
Didanyoneassistyouinfillingoutthisapplication? YES

PreparerSurnames: PAREDESSUAREZ

PreparerGivenNames: BETTYCLARA

OrganizationName: DOESNOTAPPLY

StreetAddress: CALLEALTAGRACIANO.66

CENTRODELACIUDAD

City: MONTEPLATA

State/Province: MONTEPLATA

PostalZone/ZIPCode: 92000

Country/Region: DOMINICANREPUBLIC

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RelationshiptoYou: FRIEND
YourPersonalCopyDoNotBringtoInterview
YourPersonalCopyDoNotBringtoInterview
Ustedfirmsusolicituddemaneraelectrnicael13Mar201707:28:41(GMT05:00).Selerequirifirmarsusolicitud
personalmenteydemaneraelectrnicaalmenosqueporreglamentoquedeexentodeelloyansielformulariofueelaborado
asunombreporalguienms.SufirmaelectrnicacertificaqueustedhaledoyentendidolaspreguntasensusolicituddeVisa
deNoInmigranteyqueademstodassusrespuestassonverdaderasyrealizadasasumejorentenderyconviccin.Laentrega
deunasolicitudconteniendodeclaracionesfalsasyengaosaspuedenresultarenlanegativapermanentedeunavisapara
entraralosEstadosUnidosdeNorteamrica.Todaslasdeclaracioneshechasenestasolicitudnoestnsujetasajuramento
perodebenserhechasbajoprotestadedecirverdad.(28U.S.C.1746).

Lainformacinqueustedhaproporcionadoensusolicitudyalgunaotraenviadajuntoconsta,puedeserpuestaadisposicin
deotrasagenciasdelgobiernoconelderechoylaautoridadlegalquelesconfiereparausardichainformacin,inclusopara
propsitosdelrdenpblicoyleyesdeinmigracin.Siseobtienenhuellasdactilarescomopartedesuprocesodesolicitud,
staspuedenserusadasconelpropsitodecompararlasconotrashuellasdactilaresenelSistemadeIdentificacinde
SiguienteGeneracin(NextGenerationIdentificationSystem)NGIporsussiglaseningls,delaOficinaFederaldeInvestigacin
(FederalBureauofInvestigationFBIporsussiglaseningls)oporsussistemassubsecuentes(incluyendociviles,criminalesy
archivosexistentesdehuellasdactilares).Lafotografaqueproporcionejuntoconsusolicitudpuedeserutilizadapara
verificacindeempleouotrospropsitoscompetentesalalegislacindelosEstadosUnidosdeNorteamrica.

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