Ds 160 Form Sample PDF Details

The DS-160, Nonimmigrant Visa Application form is used by applicants from countries seeking to participate in the U.S. Visa Waiver Program. The DS-160 must be completed and submitted electronically via the Electronic System for Travel Authorization (ESTA). The following provides a sample of the DS-160 form. It is important to review all information carefully before submission. The purpose of this blog post is to provide a basic overview of the DS-160 form as well as to offer a sampler of what the form looks like. We strongly advise readers to review all relevant information carefully before submitting their application. For more detailed instructions and/or assistance with completing your application, please visit estahelp.dhs.gov or contact the Department of Homeland Security at 1-888-467-2071. Thank you!

QuestionAnswer
Form NameDs 160 Form Sample
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesds 160 pdf, ds 160 form download pdf, ds 160, ds 160 form sample

Form Preview Example

U.S. Department of State

NONIMMIGRANT VISA APPLICATION

Approved OMB 1405-0018 Expires 09/30/2007 Estimated Burden 1 hour See Page 2

PLEASE TYPE OR PRINT YOUR ANSWERS IN THE SPACE PROVIDED BELOW EACH ITEM

1. Passport Number

2. Place of Issuance:

 

 

 

 

 

DO NOT WRITE IN THIS SPACE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

Country

 

State/Province

B-1/B-2 MAX

B-1 MAX

B-2 MAX

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

MAX

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Visa Classification

3. Issuing Country

 

4. Issuance Date (dd-mMm-yyyy)

5. Expiration Date (dd-mMm-yyyy)

Mult or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Number of Applications

 

 

 

 

 

 

 

 

 

 

 

 

Months

 

 

 

 

 

 

 

 

 

6. Surnames (As in Passport)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Validity

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Issued/Refused

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

On

 

 

By

 

 

 

 

 

 

 

7. First and Middle Names (As in Passport)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Under SEC.

214(b)

221(g)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. Other Surnames Used (Maiden, Religious, Professional, Aliases)

 

 

 

 

Other

 

 

 

 

 

 

INA

 

 

 

 

 

 

 

 

 

 

 

 

Reviewed By

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9. Other First and Middle Names Used

 

 

 

 

10. Date of Birth (dd-mmm-yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11. Place of Birth:

 

 

 

 

 

 

12. Nationality

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State/Province

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13. Sex

14. National Identification Number

15. Home Address (Include apartment number, street, city, state or province, postal zone and country)

 

 

 

 

 

 

Male

(If applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16. Home Telephone Number

 

 

............................ Business Phone Number

 

............................

Mobile/Cell Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

...................................................................................................................................................................................................................................................................................................................................................

Fax Number

Business Fax Number

Pager Number

17. Marital Status

Married

Single (Never Married)

Widowed Divorced Separated

18. Spouse's Full Name (Even if divorced or separated. Include maiden name.)

19.Spouse's DOB (dd-mmm-yyyy)

20. Name and Address of Present Employer or School

 

Name:

Address:

21.Present Occupation (If retired, write "retired". If student, write "student".)

22.When Do You Intend To Arrive In The U.S.? (Provide specific date if known)

23. E-Mail Address

24.At What Address Will You Stay in The U.S.?

25.Name and Telephone Numbers of Person in U.S. Who You Will Be Staying With or Visiting for Tourism or Business

Name

..............................

Home Phone

 

....................................................................................................................................................................................................................................

Business Phone

Cell Phone

26.How Long Do You Intend 27. What is The Purpose of Your Trip? To Stay in The U.S.?

28. Who Will Pay For Your Trip? 29. Have You Ever Been in The U.S.?

Yes

No

WHEN?

FOR HOW LONG?

BARCODE

DO NOT WRITE IN THIS SPACE

50 mm x 50 mm

PHOTO

staple or glue photo here

DS-156

PREVIOUS EDITIONS OBSOLETE

Page 1 of 2

09-2004

 

 

30. Have You Ever Been Issued a U.S. Visa?

 

Yes

No

31. Have You Ever Been Refused a U.S. Visa?

Yes

No

WHEN?

 

 

 

 

 

WHEN?

 

 

 

 

 

WHERE?

 

 

 

 

 

 

WHERE?

 

 

 

 

 

WHAT TYPE OF VISA?

 

 

 

 

 

WHAT TYPE OF VISA?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

32.

Do You Intend To Work in The U.S.?

Yes

No

 

 

33. Do You Intend To Study in The U.S.?

Yes

No

 

(If YES, give the name and complete address of U.S. employer.)

 

 

(If YES, give the name and complete address of the school.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

34.

Names and Relationships of Persons Traveling With You

 

 

 

 

 

 

 

 

 

35.

 

 

Has Your U.S. Visa Ever Been Cancelled or Revoked?

Yes

No

36. Has Anyone Ever Filed an Immigrant Visa Petition on Your Behalf?

Yes

No If Yes, Who?

37.Are Any of The Following Persons in The U.S., or Do They Have U.S. Legal Permanent Residence or U.S. Citizenship?

Mark YES or NO and indicate that person's status in the U.S. (i.e., U.S. legal permanent resident, U.S. citizen, visiting, studying, working, etc.).

YES

NO

Husband/

 

YES

NO

Fiance/

 

YES

NO

Wife

 

Fiancee

 

 

 

 

 

 

 

 

 

YES

NO

Father/

 

YES

NO

Son/

 

Brother/

 

Mother

 

Daughter

 

Sister

 

 

 

 

 

 

 

 

38. IMPORTANT: ALL APPLICANTS MUST READ AND CHECK THE APPROPRIATE BOX FOR EACH ITEM.

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). Is any of the following applicable to you?

Have you ever been arrested or convicted for any offense or crime, even though subject of a pardon, amnesty or other

YES

NO

 

similar legal action? Have you ever unlawfully distributed or sold a controlled substance (drug), or been a prostitute or

 

 

procurer for prostitutes?

 

 

Have you ever been refused admission to the U.S., or been the subject of a deportation hearing, or sought to obtain or

YES

NO

 

assist others to obtain a visa, entry into the U.S., or any other U.S. immigration benefit by fraud or willful

 

 

misrepresentation or other unlawful means? Have you attended a U.S. public elementary school on student (F) status or

 

 

a public secondary school after November 30, 1996 without reimbursing the school?

 

 

Do you seek to enter the United States to engage in export control violations, subversive or terrorist activities, or any

YES

NO

other unlawful purpose? Are you a member or representative of a terrorist organization as currently designated by the

 

 

U.S. Secretary of State? Have you ever participated in persecutions directed by the Nazi government of Germany; or

 

 

have you ever participated in genocide?

 

 

Have you ever violated the terms of a U.S. visa, or been unlawfully present in, or deported from, the United States?

YES

NO

Have you ever withheld custody of a U.S. citizen child outside the United States from a person granted legal custody by

YES

NO

 

a U.S. court, voted in the United States in violation of any law or regulation, or renounced U.S. citizenship for the

 

 

purpose of avoiding taxation?

 

 

Have you ever been afflicted with a communicable disease of public health significance or a dangerous physical or mental

YES

NO

 

disorder, or ever been a drug abuser or addict?

 

 

While a YES answer does not automatically signify ineligibility for a visa, if you answered YES you may be required to personally appear before a consular officer.

39. Was this Application Prepared by Another Person on Your Behalf?

Yes

No

(If answer is YES, then have that person complete item 40.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

40. Application Prepared By:

 

 

 

 

 

 

 

NAME:

 

 

 

 

Relationship to Applicant:

 

 

 

 

 

ADDRESS:

 

 

 

 

 

 

 

 

Signature of Person Preparing Form:

 

 

 

 

DATE (dd-mmm-yyyy)

 

 

41.I certify that I have read and understood all the questions set forth in this application and the answers I have furnished on this form are true and correct to the best of my knowledge and belief. I understand that any false or misleading statement may result in the permanent refusal of a visa

or denial of entry into the United States. I understand that possession of a visa does not automatically entitle the bearer to enter the United States of America upon arrival at a port of entry if he or she is found inadmissible.

APPLICANT'S SIGNATURE

 

DATE (dd-mmm-yyyy)

Privacy Act and Paperwork Reduction Act Statements

INA Section 222(f) provides that visa issuance and refusal records 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 visa records may be made available to a court which certifies that the information contained in such records is needed in a case pending before the court.

Public reporting burden for this collection of information is estimated to average 1 hour per response, including time required for searching existing data sources, gathering the necessary data, providing the information required, and reviewing the final collection. You do not have to provide the information unless this collection displays a currently valid OMB number. Send comments on the accuracy of this estimate of the burden and recommendations for reducing it to: U.S. Department of State, A/RPS/DIR, Washington, DC 20520.

DS-156

Page 2 of 2

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Completing part 1 of ds 160 form sample

2. Once your current task is complete, take the next step – fill out all of these fields - Single Never Married, Widowed, Divorced, Separated, Name and Address of Present, Present Occupation If retired, When do you intend to arrive in, EMail Address, At what address will you stay in, Name and telephone numbers of, Business Phone Cell Phone, How long do you intend to stay in, What is the purpose of your trip, BARCODE, and DO NOT WRITE IN THIS SPACE with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

How one can prepare ds 160 form sample portion 2

3. This next stage will be straightforward - fill out all the blanks in Who will pay for your trip, Have you ever been in the US, Yes, When, For how long, PREVIOUS EDITIONS OBSOLETE, and Page of to complete this process.

Stage no. 3 of filling out ds 160 form sample

When it comes to Have you ever been in the US and Yes, be sure you review things in this current part. The two of these are the most important fields in this file.

4. This next section requires some additional information. Ensure you complete all the necessary fields - Have you ever been issued a US, Yes, Have you ever been refused a US, Yes, When, Where, What type of visa, Do you intend to work in the US, Yes, If YES give the name and complete, When, Where, What type of visa Do you intend, Yes, and If YES give the name and complete - to proceed further in your process!

Where, Yes, and When inside ds 160 form sample

5. Finally, this last section is precisely what you need to finish before submitting the form. The blank fields in this case are the following: Have you ever been refused, Do you seek to enter the United, Have you ever violated the terms, Have you ever withheld custody of, Have you ever been afflicted with, Yes, Yes, Yes, Yes, While a YES answer does not, Yes, Application Prepared By, Name, Address, and Relationship to Applicant.

ds 160 form sample conclusion process outlined (stage 5)

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