1、Personal Information 1OMB CONTROL NUMBER: 1405-0185FORM NUMBER: DS-260 EXPIRATION DATE: 01/31/2016 ESTIMATED BURDEN: 120 MINNOTE: Data on this page must match the information as it is written in your passport or travel documents. Surnames Given NamesFull Name in Native AlphabetHave you ever used oth
2、er names (i.e., maiden, religious, professional, alias, etc.)? （yes）(no)Sex(male) female)Current Marital StatusDate of Birth(Format: DD-MMM-YYYY)City of BirthState/Province of BirthCountry/Region of BirthPersonal Information 2Country/Region of Origin (Nationality)Document TypeDocument IDCountry/Auth
3、ority that Issued DocumentIssuance Date(Format: DD-MMM-YYYY)Expiration Date(Format: DD-MMM-YYYY) Do you hold or have you held any nationality other than the one you have indicated above? (yes)(no)Present Address Street Address (Line 1)Street Address (Line 2) *Optional CityState/ProvincePostal Zone/Z
4、IP CodeCountry/RegionStarted Living Here(Format: MMM-YYYY) Previous AddressesHave you lived anywhere other than this address since the age of sixteen? (Date you turned sixteen: 23-Mar-2001)(yes) (no)Street Address (Line 1)Street Address (Line 2) *OptionalCityState/ProvincePostal Zone/ZIP CodeCountry
5、/RegionStarted Living Here(Format: MMM-YYYY) To Date(Format: MMM-YYYY)PhonePrimary Phone NumberSecondary Phone NumberWork Phone NumberEmailEmail AddressMailing and Permanent Address InformationIs your Mailing Address the same as your Present Address?(yes) (no)Permanent AddressPlease provide the foll
6、owing information on where you intend to live after arrival in the United States. Name of person currently living at addressU.S. Street Address (Line 1)U.S. Street Address (Line 2) *Optional CityStateZIP CodePhone NumberIs this address where you want your Permanent Residence Card (Green Card) mailed
7、? (yes) (no)Family Information: ParentsFatherSurnamesGiven NamesDate of Birth(Format: DD-MMM-YYYY) Place of Birth CityState/ProvinceCountry/RegionIs your father still living?(yes) (no)Current AddressStreet Address (Line 1)Street Address (Line 2) *Optional CityState/ProvincePostal Zone/ZIP CodeCountr
8、y/RegionMotherSurnames at BirthGiven NamesDate of Birth(Format: DD-MMM-YYYY) CityState/ProvinceCountry/RegionIs your mother still living?(yes) (no)Is your mothers address the same as your fathers?(yes) (no)Current AddressStreet Address (Line 1)Street Address (Line 2) *OptionalCityState/ProvincePosta
9、l Zone/ZIP CodeCountry/RegionFamily Information: Previous Spouse NOTE: Please provide the following information on all of your previous spouses, including those deceased. Do you have any previous spouses?(yes) (no)Family Information: ChildrenDo you have any children?(yes) (no)Previous U.S. Travel In
10、formationHave you ever been in the U.S.?(yes) (no)Have you ever been issued a U.S. Visa?*yes) (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 port of entry? (yes) (no)Present Work/Education/Training Informati
11、onPrimary OccupationPresent Employer or School NamePresent Employer or School address: Street Address (Line 1) Street Address (Line 2) *OptionalCityState/ProvincePostal Zone/ZIP CodeCountry/RegionDo you have other occupations?(yes) (no)n which occupation do you intend to work in the U.S.?Previous Wo
12、rk/Education/Training Information Were you previously employed?(yes) (no)Have you attended any educational institutions at a secondary level or above? (yes) (no)Additional Work/Education/Training InformationHave you ever served in the military?(yes) (no)Have you belonged to, contributed to, or worke
13、d for any professional, social, or charitable organization?(yes) (no)Do you have any specialized skills or training, such as firearms, explosives, nuclear, biological, or chemical experience?(yes) (no)Have you ever served in, been a member of, or been involved with a paramilitary unit, vigilante uni
14、t, rebel group, guerrilla group, or insurgent organization?(yes) (no)Can you speak and/or read languages other than your native language?(yes) (no)List the languages that you speak and/or read:Petitioner InformationPetitioner is myPetitioner Petitioner SurnamesPetitioner Given NamesAddress and Phone
15、 Number of PetitionerStreet Address (Line 1)Street Address (Line 2) *OptionalCityState/ProvincePostal Zone/ZIP CodeCountry/RegionTelephoneMobile/Cell TelephoneEmail AddressSecurity and Background: Medical and Health Information Do you have a communicable disease of public health significance such as
16、 tuberculosis (TB)?(yes) (no)Do you have documentation to establish that you have received vaccinations in accordance with U.S. law?(yes) (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?(yes) (no)Are you or have yo
17、u ever been a drug abuser or addict?(yes) (no)Security and Background: Criminal InformationHave you ever been arrested or convicted for any offense or crime, even though subject of a pardon, amnesty, or other similar action?(yes) (no)Have you ever violated, or engaged in a conspiracy to violate, any
18、 law relating to controlled substances?(yes) (no)Are you the spouse, son, or daughter of an individual who has violated any controlled substance trafficking law, and have knowingly benefited from the trafficking activities in the past five years?(yes) (no)Are you coming to the United States to engag
19、e in prostitution or unlawful commercialized vice or have you been engaged in prostitution or procuring prostitutes within the past 10 years?(yes) (no)Have you ever been involved in, or do you seek to engage in, money laundering?(yes) (no)Have you ever committed or conspired to commit a human traffi
20、cking offense in the United States or outside the United States?(yes) (no)Have you ever knowingly aided, abetted, assisted, or colluded with an individual who has been identified by the President of the United States as a person who plays a significant role in a severe form of trafficking in persons
21、?(yes) (no)Are you the spouse, son, or daughter of an individual who has committed or conspired to commit a human trafficking offense in the United States or outside the United States and have you within the last five years, knowingly benefited from the trafficking activities?(yes) (no)Security and
22、Background: Security Information 1Do you seek to engage in espionage, sabotage, export control violations, or any other illegal activity while in the United States?(yes) (no)Do you seek to engage in terrorist activities while in the United States or have you ever engaged in terrorist activities?(yes
23、) (no)Have you ever or do you intend to provide financial assistance or other support to terrorists or terrorist organizations?(Yes) (no)Are you a member or representative of a terrorist organization?(yes) (no)Have you ever ordered, incited, committed, assisted, or otherwise participated in genocide
24、?(yes) (no)Have you ever committed, ordered, incited, assisted, or otherwise participated in torture?(yes) (no)Have you committed, ordered, incited, assisted, or otherwise participated in extrajudicial killings, political killings, or other acts of violence?(yes) (no)Have you ever engaged in the recruitment of or the use of child soldiers?(yes) (no)Have you, while serving as a government official, been responsible for or directly carried out, at any time, particularly severe violations of religious freedom?(yes) (no)
