IMPORTANT – PLEASE READ THE INSTRUCTIONS
• Failure to answer every question will not necessarily preclude visa issuance, as the application is considered in its entirety.
• If you believe a particular question does not apply to you or your circumstances, please write "not applicable" or "N/A."
• If you need more space to respond to a question, please continue under the same section. For example, if you need to add additional addresses and contact information, press “Enter” and add your additional information under the Address and Contact section. Please do not use charts and/or graphs on the form. Do not change the layout and/or format of the form.
• Aside from your name, date of birth, and visa classification, please only provide information not included in your current visa application; for example, if all of your children are listed in your current visa application (Form DS-160 or DS-260), you do not need to list them again.
1- Personal Information
Surname(s):
Given Name(s):
Date of Birth (mm-dd-yyyy)
Case Number/Visa Type/Classification:
2- Passport and Travel History
Have you travelled to any country (other than your country of residence) in the last 15 years? • Yes • No
If yes, provide details for each trip, including locations visited, date visited, source of funds, and length of stay.
Have you ever held a passport other than the passport listed in your visa application?
• Yes • No
If yes, provide the following information.
Country of Issuance Passport Number
3- Relatives
Siblings (brothers and sisters) - Provide the full name(s) and date of birth of any sibling (full, half, step, adopted), living or deceased.
Surname(s) Given Name(s) Date of Birth (mm-dd-yyyy)
Children - Provide the full name(s) and date of birth of any child (minor and adult), living or deceased.
Surname(s) Given Name(s) Date of Birth (mm-dd-yyyy)
Spouse - Provide the full name(s) of any current or previous spouse or civil/domestic partner, living or deceased.
Surname(s) Given Name(s) Date of Birth (mm-dd-yyyy)
4- Address and Contact Information
Address - Provide all addresses where you have lived during the last 15 years, if not already provided in your application.
Dates of Residence (mm-dd-yyyy)
Address
Street Address 1:
Street Address 2:
City:
State/Province:
Postal Zone/Zip Code:
Country/Region:
Phone Number - Provide all phone numbers you have used in the last five years, including primary, secondary, work, home, and mobile numbers.
Phone Numbers:
E-mail - Provide all email addresses you have used in the last five years, including primary, secondary, work, personal, and educational addresses.
E-mail Addresses:
5- Social Media
Please provide your unique user name for any websites or applications you have used to create or share content (photos, videos, status updates, etc.) as part of a public profile within the last five years.
Social Media Platform
Social Media Identifier (Name/Handle)
6- Employment History
Provide the following information on all employers in the last fifteen years, if not already provided in your application.
Employer Name:
Dates of Employment (mm-dd-yyyy):
Street Address 1:
Street Address 2:
City:
State/Province:
Postal Zone/Zip Code:
Country/Region:
Telephone Number:
Job Title:
Job Description:
The information provided in this application and other information submitted may be provided to other U.S. government agencies having statutory or other lawful authority to use such information, including for law enforcement and immigration law enforcement purposes. I understand that any willfully false or misleading statement or willful concealment of a material fact made by me herein may subject me to permanent exclusion from the United States and, if I am admitted to the United States, may subject me to criminal prosecution and/or removal.
• Yes • No
CONFIDENTIALITY STATEMENT
AUTHORITIES: The information on this form is requested pursuant to Section 212(a) and 221 and as required by Section 222 of the Immigration and Nationality Act. Section 222(f) provides that the records of the Department of State and of diplomatic and consular offices of the United States pertaining to the issuance and refusal of visas or permits to enter the United States shall be considered confidential and shall be used only for the formulation, amendment, administration, or enforcement of the immigration, nationality, and other laws of the United States. Certified copies of such records may, in the discretion of the Secretary of State, be made available to a court provided the court certifies that the information contained in such records is needed in a case pending before the court.
PURPOSE: The U.S. Department of State uses the information provided on this form to determine an individual's eligibility for a U.S. visa. Individuals who fail to submit this form or who do not provide all the requested information may be denied a U.S. visa. Although furnishing this information is voluntary, failure to provide this information may delay or prevent the processing of an individual visa application.
سلام این فرم 5355 که تو سفارت میدن گذاشتم جوابهاتون رو آماده داشته باشید ظاهرا تک تک اعضا باید این فرم را پر کنند پرسیدم گفتن حتی فرزند 7 ساله ام هم باید پر کند.موفق باشین.
پاسخ : برنامه لاتاری سال 2019 (Diversity Immigrant Visa Program- DV 2019)
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