Nonimmigrant Visa Application

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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: UMEZA , SILVERA Full Name in Native

Language: SILVERA UMEZA Other Names Used: NO

Sex: FEMALE

Marital Status: SINGLE

Date of Birth: 17 AUGUST 1945 Place of Birth: JAKARTA

Nationality: INDONESIA Other Nationalities: NO

National Identification

Number: 12345678910 U.S. Social Security

Number: DOES NOT APPLY U.S. Taxpayer ID Number: DOES NOT APPLY Home Address: JL. H.R RASUNA SAID

City: JAKARTA SELATAN

State/Province: DKI JAKARTA

Postal Zone/ZIP Code: 12980

Country: INDONESIA

Same Mailing Address? PILIH YES (DENGAN ALAMAT RUMAHJIKA ALAMAT SURAT MENYURAT SAMA ) PILIH NO (JIKA ALAMAT SURAT MENYURAT BERBEDA DENGAN ALAMAT RUMAH)

Mailing Address:

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)

City:

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State/Province:

Postal Zone/ZIP Code:

Country: INDONESIA Home Phone Number: 62 8317330

Work Phone Number: 62 8317330 Work Fax Number: 62 8317331 Mobile/Cell Phone Number: 62 82114198534 Email Address: silvera.umeza@iief.or.id Passport Number: A123456

Passport Book Number: DOES NOT APPLY Country/Authority that Issued Passport: INDONESIA City Where Issued: JAAKRTA SELATAN State/Province Where Issued: DKI JAKARTA Country Where Issued: INDONESIA Issuance Date: 17 AUGUST 1965 Expiration Date: 17 AUGUST 1970 Have you ever lost a passport or had one

stolen? NO

Travel Information

Principal Applicant? YES

▲ Purpose of Your Trip to U.S.

Purpose (1) : 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: AKAN DIISI OLEH IIEF

Name of Company/Organization Paying for

Trip: AKAN DIISI OLEH IIEF

Telephone: AKAN DIISI OLEH IIEF

Relationship to You: AKAN DIISI OLEH IIEF

Is the address of the party paying for your trip

the same as your Home or Mailing Address? AKAN DIISI OLEH IIEF Paying Address: AKAN DIISI OLEH IIEF

City: AKAN DIISI OLEH IIEF

State/Province: AKAN DIISI OLEH IIEF

Postal Zone/ZIP Code: AKAN DIISI OLEH IIEF

Country: AKAN DIISI OLEH IIEF

Other Persons Traveling with You: NO Have you ever been in the U.S.? NO Have you ever been issued a U.S. visa? NO 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?

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U.S. Contact Information

Contact Person Name in the U.S.: AKAN DIISI OLEH IIEF

Organization Name in the U.S.: AKAN DIISI OLEH IIEF

Relationship to You: AKAN DIISI OLEH IIEF

U.S. Contact Address: AKAN DIISI OLEH IIEF AKAN DIISI OLEH IIEF

Phone Number: AKAN DIISI OLEH IIEF

Email Address: AKAN DIISI OLEH IIEF

Family Information

Father's Surnames: KASMIAN Father's Given Names: KASMIAN Father's Date of Birth: 17 AUGUST 1900 Is your father in the U.S.? NO

Mother's Surnames: MUSRIFAH Mother's Given Names: MUSRIFAH Mother's Date of Birth: 17 AUGUST 1910 Is your mother in the U.S.? NO

Do you have any immediate relatives, not

including parents in the U.S.? NO Do you have any other relatives in the United

States? NO

Work / Education / Training Information

Primary Occupation: STUDENT

Present Employer or School Name: UNIVERSITY OF IIEF Address: JL. H.R RASUNA SAID

State/Province: DKI JAKARTA

Postal Zone/Zip Code: 12980

Country: INDONESIA Month Salary in Local Currency: NONE

Briefly Describe your Duties: NONE Were you previously employed? NO

▲ Have you attended any educational institutions other than elementary schools?

YES

DIMULAI DARI SMP SAMPAI S1

Name of Institution (1) : SMP 000

Address of Institution: JL. H.R RASUNA SAID NO 0

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

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

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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? NO Have you traveled to any countries within the last five years? NO Have you belonged to, contributed to, or

worked for any professional, social, or

charitable organization? NO Do you have any specialized skills or training, including firearms, explosives, nuclear,

biological, or chemical experience? NO Have you ever served in the military? NO 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

Security and Background Information

Do you have a communicable disease of public health significance such as tuberculosis (TB)? NO 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? NO Are you or have you ever been a drug abuser

or addict? NO

Have you ever been arrested or convicted for any offense or crime, even though subject of a pardon, amnesty, or other similar action? NO Have you ever violated, or engaged in a

conspiracy to violate, any law relating to

controlled substances? NO 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?

NO Have you ever been involved in, or do you

seek to engage in, money laundering? NO Do you seek to engage in espionage,

sabotage, export control violations, or any

other illegal activity while in the United States? NO Do you seek to engage in terrorist activities

while in the United States or have you ever

engaged in terrorist activities? NO Have you ever or do you intend to provide

financial assistance or other support to

terrorists or terrorist organizations? NO Are you a member or representative of a

terrorist organization? NO Have you ever ordered, incited, committed,

assisted, or otherwise participated in

genocide? NO

Have you ever committed, ordered, incited,

assisted, or otherwise participated in torture? NO Have you committed, ordered, incited,

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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?

NO

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?

NO

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? NO Have you voted in the United States in

violation of any law or regulation? NO Have you ever renounced United States

citizenship for the purpose of avoiding

taxation? 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: AKAN DIISI OLEH IIEF

Do you intend to study in the U.S.? AKAN DIISI OLEH IIEF

Name of School: AKAN DIISI OLEH IIEF

Course of Study: AKAN DIISI OLEH IIEF

Street Address: AKAN DIISI OLEH IIEF AKAN DIISI OLEH IIEF

Nonimmigrant Visa Application

Aplikasi Visa Nonimigran