Bevan Adams

United States Immigration Consultant

London, United Kingdom
07539437508
www.bevanadams.com

Visa Application & Information Submission Form

Please complete this form to the best of your ability. All of the information you provide will be kept
in the strictest confidence and is subject to remain privileged.

Upon completion of this form please-mail a copy to bevan@bevanadams.com, or mail it to American

Visa Services Ltd, Bevan Adams, Office #51, 56 Tavistock Place, London, WC1H 9RG.

This form should only be submitted upon completion of the £50.00 Consultation Fee.

There may be additional information required in order to best advise you, and/or to proceed with
any application.

Basic Information

Full Name: _________________________________________________________________________

E-mail Address: _____________________________________________________________________

Mobile Phone Number: ______________________________________________________________

Home Phone Number: _______________________________________________________________

Have you used any other names? Yes/ No (If Yes, please describe) _________________________

Sex: M/F

Date of Birth: Day__________Month____________Year______________

City of Birth: ___________________________________

State of Birth: __________________________________

Country of Birth: ________________________________

Nationality: ____________________________________

Do you hold any other nationalities? Y/N (If Yes, please describe) ___________________________

Travel Information

What type of visa do you think best serves your needs? ____________________________________
What are your intended dates of travel to the U.S.?

From: Day__________Month____________Year______________

Until: Day__________Month____________Year______________

Security & Background Information

Please read through all of the following questions and answer them accurately. Attach extra sheets
of paper if you require additional room to answer.

a) Do you have any communicable diseases of public health significance such as TB? Y/N (If
Yes, please describe)__________________________________________________________
b) Do you have a mental or physical disorder that posses or is likely to pose a threat to the
safety or welfare of yourself or others? Y/N (If Yes, please describe)___________________
c) Are you or have you ever been a drug addict or abuser? Y/N (If Yes, please describe) _____
___________________________________________________________________________
d) Do you belong to a clan or tribe? Y/N (If Yes, please describe)________________________
e) Have you belonged to, contributed to, or worked for any professional, social, or charitable
organizations? Y/N (If Yes, please describe)_______________________________________
___________________________________________________________________________
f) Do you have any specialized skills or training, such as firearms, explosives, nuclear,
biological, or chemical experience? Y/N (If Yes, please describe)______________________
g) Have you ever served in the military? Y/N (If Yes, please describe)_____________________
h) 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? Y/N (If Yes, please
describe)____________________________________________________________________
i) Have you ever been arrested or convicted for any offence or crime, even though subject of a
pardon, amnesty, or other similar action? Y/N (If Yes, please describe)_________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
j) Have you ever violated, or engaged in a conspiracy to violate, any law relating to a
controlled substance? Y/N (If Yes, please describe)_________________________________
___________________________________________________________________________
___________________________________________________________________________
k) Are you coming to the United States to engage in prostitution or unlawful criminalized vice
or have you been engaged in prostitution or procuring prostitution within the past ten
years? Y/N (If Yes, please describe)______________________________________________
l) Have you ever been involved in, or do you seek to engage in, money laundering? Y/N (If
Yes, please describe)__________________________________________________________
m) Do you seek to engage in espionage, sabotage, export control violations, or any other illegal
activity while in the United States? Y/N (If Yes, please describe)_______________________
n) Do you seek to engage in terrorist activities while in the United States or have you ever
engaged in terrorist activities? Y/N (If Yes, please describe) __________________________
o) Have you ever or do you intend to provide financial assistance or other support to terrorists
or terrorist organisations? Y/N (If Yes, please describe) _____________________________
 p) Are you a member or a representative of e terrorist origination? Y/N (If Yes, please
describe)____________________________________________________________________
q) Have you ever ordered, incited, committed, assisted, or otherwise participated in genocide?
Y/N (If Yes, please describe) ___________________________________________________
r) Have you ever ordered, incited, committed, assisted, or otherwise participated in torture?
Y/N (If Yes, please describe)____________________________________________________
s) Have you ever ordered, incited, committed, assisted, or otherwise participated in
extrajudicial killings, political killings, or other acts of violence? Y/N (If Yes, please describe)
___________________________________________________________________________
t) Have you, while serving as a government official, been responsible for or directly carried out,
at any time, particularly severe violations of religious freedom? Y/N (If Yes, please
describe)____________________________________________________________________
u) Have you ever been subject to a removal hearing or deportation from the United States?
Y/N (If Yes, please describe)____________________________________________________
___________________________________________________________________________
v) 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 wilful misrepresentation
or other unlawful means? Y/N (If Yes, please describe)______________________________
w) Have you failed to attend a hearing on removability or inadmissibility with in the last five
years in the United States? Y/N (If Yes, please describe)_____________________________
x) Have you ever been unlawfully present, overstayed the amount of time granted be
immigration official or otherwise violated the terms of a U.S. visa? Y/N (If Yes, please
describe)____________________________________________________________________
___________________________________________________________________________
y) 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? Y/N (If Yes, please describe)______________
z) Have you ever voted in the United States in violation of any law or regulation? Y/N (If Yes,
please describe)______________________________________________________________
aa) Have you ever renounced United States citizenship for the purpose of avoiding taxation?
Y/N (If Yes, please describe)____________________________________________________
bb) Have you attended a public elementary school on student (F) status or a public secondary
school after November 30, 1996 without reimbursing the school? Y/N (If Yes, please
describe)__________________________________________________________________

Declaration
I, the above [applicant], certify, by submitting this form to BEVAN ADAMS, the above information is true and correct.

By signing this agreement, I, _____ (initial), give all power of attorney as authorized by regulations to U.S. Immigration Consultant Bevan
Adams. By said regulations, I permit the aforementioned to electronically sign and submit any and all correspondence and/or applications
to the U.S. State Department.
By signing this agreement, I, _____ (initial), recognise that if I present any false or misleading information to U.S. Immigration Consultant
Bevan Adams as truthful, I will personally be held under penalty of perjury. (28.U.S.C.1746)
I certify under penalty of perjury under the laws of the United States of America that all of the foregoing and all that follows is true and
correct.

Name of Applicant: ________________________________________________________________

Date of Application: Day__________Month____________Year______________

Signature of Applicant: ______________________________________________________________