My Form - Contentivo

v16

Surnames (as listed in passport)

Given Names (Enter 'FNU' if passport has no Given Names)

Full Name in Native Alphabet (Optional: Doesn't apply/Technology Not Available)

Have you ever used other names (Past identities: i.e., maiden, religious, professional, alias, etc.)?

Yes

Provide the following information (Use + to add another):

Other Surnames (Past identities)	Other Given Names (Past identities)

Do you have a telecode that represents your name?

Yes

Telecode: 4-digit code that represents characters in some non-Roman alphabet names.

Provide the following information:

Telecode Surnames

Telecode Given Names

Sex

Marital Status

Explain

Date of Birth (As shown in passport)

City of Birth

State/Province of Birth (Optional)

Country/Region of Birth

Personal Information 2

Country / Region of Origin (Nationality)

Do you hold or have you held any nationality other than the one indicated above on nationality?

Yes

Enter all nationalities you currently hold or have previously held, regardless of whether you have formally and/or legally relinquished the nationality. If the country is no longer a nationality, select the associated country used for that location.

Provide the following information:

Other country or region of origin (Nationality)

Do you hold a passport for the other country / region of origin (nationality) indicated above?

Yes

Passport Number

Are you a permanent resident of a country or region other than your country or region of origin (nationality) indicated above?

Yes

Permanent resident: Any individual who has been legally granted by a country/region permission to live and work without time limitation in that country/region.

Other Permanent Resident Country or Region (Use + to add all the countries.)

National Identification Number (ID Number) (If it applies)

The ID number given to you by your country.

U.S. Social Security Number (SSN) (If it applies)

U.S. Taxpayer ID Number (If it applies)

Travel Information

Purpose of Trip to the U.S.

SPECIFY (A)

SPECIFY (B)

SPECIFY (C)

SPECIFY (CW)

SPECIFY (D)

SPECIFY (E)

SPECIFY (F)

SPECIFY (G)

SPECIFY (H)

SPECIFY (I)

SPECIFY (J)

SPECIFY (K)

SPECIFY (L)

SPECIFY (M)

SPECIFY (N)

SPECIFY (NATO)

SPECIFY (O)

SPECIFY (P)

SPECIFY (Q)

SPECIFY (R)

SPECIFY (S)

SPECIFY (T)

SPECIFY (TD/TN)

SPECIFY (U)

SPECIFY (PARCIS)

Principal Applicant Information

Surnames

Given names

Principal Applicant Information

Application Receipt/Petition Number

Principal Applicant Information

Surnames

Given names

Application Receipt/Petition Number

Principal Applicant Information

Surnames

Given names

Principal Applicant's Company Name

Has the principal Treaty Trader/Investor already been issued a visa?

Yes

Surnames

Given names

Principal Applicant Date of Birth

Have you made specific travel plans?

Yes

Provide a complete itinerary for your travel to the U.S.

Date of Arrival in U.S.

Arrival Flight (if known)

Arrival City

Date of Departure from U.S.

Departure Flight (if known)

Departure City

Provide the locations you plan to visit in the U.S.: (Add other locations using the + sign)

Column 1

Address where you will stay in the U.S.

Address Line 1

Address Line 2 (Optional)

City

State

Zip Code (if known)

Country

Intended Date of Arrival (Provide an estimate)

Intended Length of Stay in U.S. [Part 1] (Number)

Intended Length of Stay in U.S. [Part 2] (Duration)

Address where you will stay in the U.S.

Street Address (Line 1)

Street Address (Line 2) (Optional)

City

State

ZIP Code (If Known)

Person / entity paying for your trip

Provide the following information

Surname of person paying for the trip

Given names of person paying for trip

Telephone Number

Email (Optional)

Relationship to you

Is the address of the party paying for your trip the same as your Home or Mailing Address?

Yes

Address of Person Paying

Street Address (Line 1)

Street Address (Line 2) Optional

City

State/Province (Optional)

Postal Zone/Zip Code (Optional)

Country/Region

Provide the following information

Name of company / organization paying for trip

Telephone Number

Relationship to you

Address of company / organization paying

Address Line 1

Address Line 2 (Optional)

City

State/Province (Optional)

Postal Zone/Zip Code (optional)

Country

Travel Companions Information

Persons traveling with you: Are there other persons traveling with you?

Yes

Are you traveling as part of a group or organization?

Yes

Enter person(s) traveling with you (Use + to add more people)

Surnames	Given Names	Relationship with Person

Enter the name of the group you are traveling with: Group Name

Previous U.S. Travel Information

Have you ever been in the U.S.?

Yes

Provide information on your last 5 U.S. visits:

Date Arrived	Length of Stay	Duration

Do you or did you ever hold a U.S. Driver's License?

Yes

Have you ever been issued a U.S. Visa?

Yes

Have you ever been refused a U.S. Visa, or been refused admission to the United States, or withdrawn your application for admission at the port of entry?

Yes

Explain

Has anyone ever filed an immigrant petition on your behalf with the United States Citizenship and Immigration Services?

Yes

Explain

Address and Phone Information

Home Address

Address (Line 1)

Address (Line 2) Optional

City

State/Province (Optional if doesn't apply)

Postal Zone/Zip Code (Optional if doesn't apply)

Country/Region

Mailing Address: Is your Mailing Address the same as your Home Address?

Yes

Home Address

Address (Line 1)

Address (Line 2) Optional

City

State/Province (Optional if doesn't apply)

Postal Zone/Zip Code (Optional if doesn't apply)

Country/Region

Phone

Primary Phone Number

Secondary Phone Number (Optional if doesn't apply)

Work Phone Number (Optional if doesn't apply)

Have you used any other phone numbers in the last five years?

Yes

Additional Phone Number(s)

Use + to add more numbers

Email Address

Have you used any other email addresses in the last five years?

Yes

Additional Email Addresse(s)

Use + to add more email addresses

Social Media

Do you have a social media prescence?

Select from the list below each social media platform you have used within the last five years.

ONLY include username or handle
DO NOT provide your passwords

If you have not used any of the social media platforms in the last 5 years, select 'NONE.'

Use + to add more platforms

Social Media Platform	Username/Handle/Identifier

Do you wish to provide information about your presence on any other websites or applications you have used within the last 5 years to create or share content (photos, videos, status updates, etc.)?

Yes

Provide name of the platform and identifier (username or handle). This DOESN'T include private messaging such as WhatsApp.

Additional Social Media Platform	Additional Username/Handle/Identifier

Passport Information

Passport/Travel Document Type

Travel document should be a valid, unexpired passport or other valid, unexpired documentation that is sufficient to establish your identity and nationality.

Explain

Passport/Travel Document Number

Passport Book Number (Optional if doesn't apply)

This is an inventory control number which can be located in different places in a passport depending on the country of origin. Please contact your passport issuing authority if you are unable to determine if your passport contains a Passport Book Number.

Country/Authority that Issued Passport/Travel Document

Where was the Passport/Travel Document Issued?

City

State/Province (If shown on passport)

Country/Region

Issuance Date

Expiry Date (Optional if your passport has no expiration)

Passport/Travel Document must have at least 6 months of validity beyond the date of your visa application and/or your arrival in the United States.

Have you ever lost a passport or had one stolen?

Yes

Provide the following information (use + for any additional passports):

Passport Number (If you know)	Country that issued passport	Explain

U.S. Point of Contact Information

Contact Person or Organization in the United States (Optional IF you DON'T know)

Point of contact in the U.S. can be any individual in the U.S. who knows you and can verify, if necessary, your identity.

You may enter the name of the store, company, or organization you plan to visit during your trip if you don't know personally anyone in the U.S.

Surnames

Given Names

Organization Name (If you know)

Relationship to you

Address and Phone Number of Point of Contact

U.S. Street Address (Line 1)

U.S. Street Address (Line 2) (Optional)

City

State

ZIP Code (If known)

Phone Number

Email Address (If known)

Family Information: Relatives

Father's Full Name and Date of Birth

Surnames (If you know)

Given Names (If you know)

Date of Birth (If you know)

Is your father in the U.S.?

Yes

Father's Status

Mother's Full Name and Date of Birth

Surnames (If you know)

Given Names (If you know)

Date of Birth (If you know)

Is your mother in the U.S.?

Yes

Mother's Status

Do you have any immediate relatives, not including parents, in the United States?

Yes

Immediate relatives can be fiancé/fiancée, spouse (husband/wife), child (son/daughter), or sibling (brother/sister).

Provide the following information (Use + for additional relatives):

Surnames	Given Names	Relationship to You	Relative's Status

Do you have any other relatives in the United States?

Yes

Former Spouse

Number of Former Spouses:

Surnames

Given Names

Date of Birth

Country/Region or Origin (Nationality)

City of Birth (If you know)

Country/Region of Birth

Date of Marriage

Date of Marriage Ended

How the Marriage Ended

Country/Region Marriage was Terminated

Deceased Spouse

Surnames

Given Names

Date of Birth

Country/Region or Origin (Nationality)

City of Birth (If you know)

Country/Region of Birth

Enter Current Spouse Information/Civil Union Partner/Common Law Marriage.
Full Name (For Spouse, include Maiden Name)

Surnames

Given Names

Date of Birth

Country/Region or Origin (Nationality)

City of Birth (If you know)

Country/Region of Birth

Spouse's Address

Other Address

Street Address (Line 1)

Street Address (Line 2) (Optional)

City

State/Province (If you know)

Postal Zone/Zip Code (If you know)

Country/Region

Present Work/Education/Training Information

Note: Provide the following information concerning your current employment or education.

Primary Occupation

Explain

Present Employer or School Name:

Present employer or school address:

Street Address (Line 1)

Street Address (Line 2) (Optional)

City

State/Province (if it applies)

Postal zone/Zip Code (if it applies)

Country/Region

Employer/School Phone Number

Start Date

Monthly Income in Local Currency (if employed) (Optional)

Briefly describe your duties:

Were you previously employed?

Yes

Employer Name:

Employer Address

Street Address (Line 1)

Street Address (Line 2) (Optional)

City

State/Province (if it applies)

Postal zone/Zip Code (if it applies)

Country/Region

Employer Phone Number

Job Title

Supervisor's Surname (If you know)

Supervisor's Given Names (If you know)

Employment Date From

Employment Date To

Briefly describe your duties:

Have you attended any educational institutions at a secondary level or above?

Yes

Answer YES if you have ever attended, for any length of time, a highschool or secondary (or its equivalent in your country) or college, university, graduate school, a doctoral program, or a vocational program.

Name of Institution

Institution Address

Street Address (Line 1)

Street Address (Line 2) (Optional)

City

State/Province (if it applies)

Postal zone/Zip Code (if it applies)

Country/Region

Course of Study

Date of Attendance From

Date of Attendance To

Do you belong to a clan or tribe?

Yes

Provide the Clan or Tribe Name

Provide a List of Languages You Speak (Use + to add more languages)

Language Name

Have you traveled to any countries/regions within the last five years?

Yes

Provide a List of Countries/Regions Visited (Use + to add more countries)

Country/Region

Have you belonged to, contributed to, or worked for any professional, social, or charitable organization?

Yes

Provide a List of Organizations (Use + to add more organizations)

Organization Name

Do you have any specialized skills or training, such as firearms, explosives, nuclear, biological, or chemical experience?

Yes

Explain

Have you ever served in the military?

Yes

Provide the following information

Name of Country/Region

Branch of Service

Rank/Position

Military Specialty

Date of Service From

Date of Service 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

Explain

Security and Background

For the following questions, a Visa may not be issued to persons who are within specific categories defined by law as inadmissible to the United States (except when a waiver is obtained in advance). Are any of the following applicable to you?

Do you have a communicable disease of public health significance? (Such diseases include chancroid, gonorrhea, granuloma inguinale, infectious leprosy, lymphogranuloma, venereum, infectious stage syphilis, active TB, and other diseases determined by the Department of Health and Human Services.)
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?
Are you or have you ever been a drug abuser or addict?
Have you ever been arrested or convicted for any offense or crime, even though subject of a pardon, amnesty, or other similar action?
Have you ever violated, or engaged in conspiracy to violate, any law relating to controlled substances?
Are you coming to the United States to engage in prostitution or unlawful commercialized vices?
Have you ever been involved, or do you seek to engage in money laundering?
Have you ever committed or conspired to commit a human trafficking offense?
Have you ever knowingly aided, abetted, assisted or colluded with an individual who has committed a severe human trafficking offense?
Are you the spouse, son, or daughter of an individual who has committed or conspired to commit a human trafficking offense in the U.S. or outside the U.S. and knowingly benefitted within the last 5 years from the trafficking activities?
Do you seek to engage in espionage, sabotage, export control violations, or any other illegal activity while in the U.S.?
Do you seek to engage in terrorist activities while in the U.S. or have you ever engaged in terrorist activities?
Have you ever or do you intend to provide financial assistance or other support to terrorist or terrorist organizations?
Are you a member of representative of a terrorist organization?
Are you the spouse, son, or daughter of an individual who has engaged in terrorist activity, including providing financial assistance or other support to terrorists in the last 5 years?
Have you ever ordered, incited, committed, assisted, or otherwise participated in genocide?
Have you ever committed, ordered, incited, assisted, or otherwise participated in torture?
Have you ever committed, ordered, incited, assisted, or otherwise participated in extrajudicial killings, political killings, or other acts or violence?
Have you ever engaged in the recruitment or the use of child soldiers?
Have you ever, while serving as a government official, been responsible for or directly carried out, at any time, particularly severe violations or religious freedom?
Have you ever been directly involved in the establishment or enforcement of population controls forcing a woman/man to undergo an abortion/sterilization against her/his free choice?
Have you been directly involved in the coercive transplantation of human organs or bodily tissue?
Have you ever sought to obtain or assist others to obtain a visa, entry into the U.S., or any other U.S. immigration benefit by fraud or other unlawful means?
HAVE YOU ever been removed or deported from any country?
Have you ever withheld custody or a U.S. citizen child outside the U.S. from a person granted legal custody by a U.S. Court?
Have you voted in the U.S. in violation of any law or regulation?
Have you ever renounced U.S. citizenship for the purposes of avoiding taxation?

Are you in violation of any of the above questions?

Yes

No to All

If you are in violation of any of the above, please include the entry number and the explanation. (Use + to add more violations)

Entry Number	Explanation

Personal Information 2

Travel Information

Travel Companions Information

Previous U.S. Travel Information

Address and Phone Information

Social Media

Passport Information

U.S. Point of Contact Information

Family Information: Relatives

Present Work/Education/Training Information

Security and Background

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