Aplikasi Visa Nonimigran
Nonimmigrant Visa Application Application - Sensitive But Unclassified(SBU) Print Application
Back: Confirmation Page
Photo Provided:
Confirmation Number: Personal, Address, Phone, and Passport Information Name Provided: Full Name in Native Language: Other Names Used:
SILVERA UMEZA
Sex: Marital Status: Date of Birth: Place of Birth: Nationality: Other Nationalities:
FEMALE SINGLE 17 AUGUST 1945 JAKARTA INDONESIA NO
National Identification Number: U.S. Social Security Number: U.S. Taxpayer ID Number: Home Address: City: State/Province: Postal Zone/ZIP Code: Country: Same Mailing Address?
Mailing Address:
City:
UMEZA , SILVERA NO
12345678910 DOES NOT APPLY DOES NOT APPLY JL. H.R RASUNA SAID JAKARTA SELATAN DKI JAKARTA 12980 INDONESIA PILIH YES (JIKA ALAMAT SURAT MENYURAT SAMA DENGAN ALAMAT RUMAH) PILIH NO (JIKA ALAMAT SURAT MENYURAT BERBEDA DENGAN ALAMAT RUMAH) JIKA PILIH YES (KOLOM INI TIDAK USAH DIISI) JIKA PILIH NO (ISI DENGAN ALAMAT SURAT MENYURAT AGAR SEMUA DOKUMEN YANG DIKIRIM VIA POST CEPAT SAMPAI DAN DAPAT DITERIMA) JIKA PILIH YES (KOLOM INI TIDAK USAH DIISI) JIKA PILIH NO (ISI DENGAN ALAMAT SURAT MENYURAT AGAR SEMUA DOKUMEN YANG DIKIRIM VIA POST CEPAT SAMPAI DAN DAPAT DITERIMA)
State/Province:
Postal Zone/ZIP Code: Country: Home Phone Number: Work Phone Number: Work Fax Number: Mobile/Cell Phone Number: Email Address: Passport Number: Passport Book Number: Country/Authority that Issued Passport: City Where Issued: State/Province Where Issued: Country Where Issued: Issuance Date: Expiration Date: Have you ever lost a passport or had one stolen?
JIKA PILIH YES (KOLOM INI TIDAK USAH DIISI) JIKA PILIH NO (ISI DENGAN ALAMAT SURAT MENYURAT AGAR SEMUA DOKUMEN YANG DIKIRIM VIA POST CEPAT SAMPAI DAN DAPAT DITERIMA) JIKA PILIH YES (KOLOM INI TIDAK USAH DIISI) JIKA PILIH NO (ISI DENGAN ALAMAT SURAT MENYURAT AGAR SEMUA DOKUMEN YANG DIKIRIM VIA POST CEPAT SAMPAI DAN DAPAT DITERIMA) INDONESIA 62 8317330 62 8317330 62 8317331 62 82114198534
[email protected] A123456 DOES NOT APPLY INDONESIA JAAKRTA SELATAN DKI JAKARTA INDONESIA 17 AUGUST 1965 17 AUGUST 1970 NO
Travel Information Principal Applicant? ▲ Purpose of Your Trip to U.S. Purpose (1) :
YES STUDENT/EXCHANGE VISA (F, J, M, Q)
▲ Specific Travel Plan?
YES
Date of Arrival in U.S.:
12 MARCH 2011
Arrival City:
COLORADO
Date of Departure from U.S.:
7 MAY 2011
Departure City:
COLORADO
▲ The Location you plan to visit in the U.S.: Location (1):
USA
Address where you will stay in the U.S:
AKAN DIISI OLEH IIEF
Person/Entity Paying for Your Trip: Name of Company/Organization Paying for Trip: Telephone: Relationship to You: Is the address of the party paying for your trip the same as your Home or Mailing Address? Paying Address: City: State/Province: Postal Zone/ZIP Code: Country:
AKAN DIISI OLEH IIEF
Other Persons Traveling with You:
NO
Have you ever been in the U.S.? Have you ever been issued a U.S. visa? Have you ever been refused a U.S. Visa, been refused admission to the United States, or withdrawn your application for admission at the point of entry?
NO NO
AKAN DIISI OLEH IIEF AKAN DIISI OLEH IIEF AKAN DIISI OLEH IIEF AKAN DIISI OLEH IIEF AKAN AKAN AKAN AKAN AKAN
NO
DIISI DIISI DIISI DIISI DIISI
OLEH OLEH OLEH OLEH OLEH
IIEF IIEF IIEF IIEF IIEF
U.S. Contact Information Contact Person Name in the U.S.: Organization Name in the U.S.: Relationship to You: U.S. Contact Address: Phone Number: Email Address:
AKAN AKAN AKAN AKAN AKAN AKAN AKAN
DIISI DIISI DIISI DIISI DIISI DIISI DIISI
OLEH OLEH OLEH OLEH OLEH OLEH OLEH
IIEF IIEF IIEF IIEF IIEF IIEF IIEF
Family Information Father's Surnames: Father's Given Names: Father's Date of Birth: Is your father in the U.S.? Mother's Surnames: Mother's Given Names: Mother's Date of Birth: Is your mother in the U.S.? Do you have any immediate relatives, not including parents in the U.S.? Do you have any other relatives in the United States?
KASMIAN KASMIAN 17 AUGUST 1900 NO MUSRIFAH MUSRIFAH 17 AUGUST 1910 NO NO NO
Work / Education / Training Information Primary Occupation: Present Employer or School Name: Address: City: State/Province: Postal Zone/Zip Code: Country: Month Salary in Local Currency: Briefly Describe your Duties:
STUDENT UNIVERSITY OF IIEF JL. H.R RASUNA SAID JAKARTA SELATAN DKI JAKARTA 12980 INDONESIA NONE NONE
Were you previously employed?
NO YES
▲ Have you attended any educational institutions other than elementary schools?
DIMULAI DARI SMP SAMPAI S1
Name of Institution (1) :
SMP 000
Address of Institution:
JL. H.R RASUNA SAID NO 0
City:
JAKARTA SELATAN
State/Province:
DKI JAKARTA
Postal Zone/ZIP Code:
12980
Country:
INDONESIA
Course of Study:
NONE
Date of Attendance From:
17 AUGUST 1950
Date of Attendance To:
17 AUGUST 1953
Name of Institution (1) :
SMA 000
Address of Institution:
JL. H.R RASUNA SAID NO 0
City:
JAKARTA SELATAN
State/Province:
DKI JAKARTA
Postal Zone/ZIP Code:
12980
Country:
INDONESIA
Course of Study:
NONE
Date of Attendance From:
17 AUGUST 1953
Date of Attendance To:
17 AUGUST 1958
Name of Institution (1) :
UNIVERSITY OF IIEF
Address of Institution:
JL. H.R RASUNA SAID
City:
JAKARTA SELATAN
State/Province:
DKI JAKARTA
Postal Zone/ZIP Code:
12980
Country:
INDONESIA
Course of Study:
EDUCATION
Date of Attendance From:
17 AUGUST 1958
Date of Attendance To:
17 AUGUST 1962
Do you belong to a clan or tribe? Have you traveled to any countries within the last five years? Have you belonged to, contributed to, or worked for any professional, social, or charitable organization? Do you have any specialized skills or training, including firearms, explosives, nuclear, biological, or chemical experience? Have you ever served in the military? 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?
NO NO
NO
NO NO NO
Security and Background Information Do you have a communicable disease of public health significance such as tuberculosis (TB)? 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 a conspiracy to violate, any law relating to controlled substances? Are you coming to the United States to engage in prostitution or unlawful commercialized vice or have you been engaged in prostitution or procuring prostitutes within the past 10 years? Have you ever been involved in, or do you seek to engage in, money laundering? Do you seek to engage in espionage, sabotage, export control violations, or any other illegal activity while in the United States? Do you seek to engage in terrorist activities while in the United States or have you ever engaged in terrorist activities? Have you ever or do you intend to provide financial assistance or other support to terrorists or terrorist organizations? Are you a member or representative of a terrorist organization? 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 committed, ordered, incited, assisted, or otherwise participated in
NO NO NO
NO NO
NO NO
NO NO NO NO NO NO NO
extrajudicial killings, political killings, or other acts of violence? Have you, while serving as a government official, been responsible for or directly carried out, at any time, particularly severe violations of religious freedom? 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 willful misrepresentation or other unlawful means? 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? Have you voted in the United States in violation of any law or regulation? Have you ever renounced United States citizenship for the purpose of avoiding taxation?
NO
NO
NO NO NO
Student/Exchange Visa Information ▲Additional Point of Contact Information: Name(1):
Diisi dengan Contact Person/Referensi di Indonesia di luar keluarga (dan IIEF) misalnya: teman, dosen dll. ALamat harus jelas, lengkap dan mudah dicapai dengan petugas pos.
Street Address: City: State/Province: Postal Zone/ZIP Code: Country: Telephone Number: Email Address:
Name(2):
Diisi dengan Contact Person/Referensi di Indonesia di luar keluarga (dan IIEF) misalnya: teman, dosen dll. ALamat harus jelas, lengkap dan mudah dicapai dengan petugas pos.
Street Address: City: State/Province: Postal Zone/ZIP Code: Country: Telephone Number: Email Address: SEVIS ID: Do you intend to study in the U.S.? Name of School: Course of Study: Street Address:
AKAN AKAN AKAN AKAN AKAN AKAN
DIISI DIISI DIISI DIISI DIISI DIISI
OLEH OLEH OLEH OLEH OLEH OLEH
IIEF IIEF IIEF IIEF IIEF IIEF
Location Information Current Location:
JAKARTA, INDONESIA
