Моля на въпросите, които изискват отговор Yes/No, отбелязвайте верния отговор с Х

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Дата	22.07.2016
Размер	119.01 Kb.
	#586

Family Information: Relatives
Present Work/Education/Training Information
Security and Background: Medical and Health Information
Security and Background: Immigration Law Violation Information

Моля на въпросите, които изискват отговор Yes/No, отбелязвайте верния отговор с Х

Personal Information 1

Surnames (фамилия по паспорт):

Given Names (име и презиме по паспорт):

Full Name in Native Alphabet (трите имена на кирилица):

Have you ever used other names (i.e., maiden, religious, professional, alias, etc.)? Yes No

Other Surnames Used (maiden, religious, professional, aliases, etc.):

Other Given Names Used:

Sex: Male Female

Marital Status:

Date of Birth:

/Изписвайте датите във формат DDMMMYYYY/

City of Birth:

State/Province of birth:

Country of birth:

Nationality:

Do you hold or have you held a nationality other than the one you have indicated above? Yes No

If yes, what?

National Identification Number (ЕГН):

U.S. Social Security Number (ако сте ходили в САЩ):

Home Address - Street Address:

/Изписвайте адреса без никакви препинателни знаци и символи/

City:

State/Province:

Postal Zone/ZIP Code:

Country:

Mailing Address: (ако е различен от постоянния)

Street Address:

City:

State/Province:

Postal Zone/ZIP Code:

Country:

Home Phone Number:

/Изписвайте номера във формат +359XXXXXXXXX/

Work Phone Number:

Work Fax number:

Mobile:

/Изписвайте номера във формат +359XXXXXXXXX/

Email Address:

Passport Number:

Passport Book Number /Не попълвайте този въпрос/

Country/Authority that Issued Passport:

Where was the Passport Issued?

State/Province *If shown on passport:

Country:

Issuance Date:

/Изписвайте датите във формат DDMMMYYYY/

Expiration Date:

/Изписвайте датите във формат DDMMMYYYY/

Have you ever lost a passport or had one stolen? Yes No

If YES, Passport Number and Country/Authority that Issued Passport

Intended Date of Arrival in the U.S.:

/Изписвайте датите във формат DDMMMYYYY/

Intended Length of Stay in U.S.:

Address Where You Will Stay in the U.S.: (тук се пише адрес на работодател. Не се приемат пощенски кутии!!!)

Street Address:

City:

State:

ZIP Code (if known):

Person/Entity Paying for Your Trip: Self other person company organization

(ако сте работили предишни години в САЩ, може да отбележите SELF, ако не сте, отбележете other person и попълнете полетата по-долу)

Surnames of Person Paying for Trip:

Given Names of Person Paying for Trip:

Telephone Number:

/Изписвайте номера във формат +359XXXXXXXXX/

Email Address:

Relationship to You:

Is the address of the party paying for your trip the same as your Home or Mailing Address?

If not, please enter: Yes No

Street Address:

/Изписвайте адреса без никакви препинателни знаци и символи/

City:

State/Province:

Postal Zone/ZIP Code:

Country:

Are there other persons traveling with you? Yes No

(Моля пишете Yes само ако пътувате с членове на семейството, като напишете и имената им)

Surnames of Person Traveling With You:

Given Names of Person Traveling With You:

Relationship with Person:

Have you ever been in the U.S.? Yes No

Date of Arrival: (ако сте ходили няколко пъти, моля напишете за всички години, в които сте били)

/Изписвайте датите във формат DDMMMYYYY/

Length of Stay:

Do you or did you ever hold a U.S. Driver’s License? Yes No

If Yes, Driver's License Number:

State of Driver's License:

Have you ever been issued a U.S. Visa? Yes No

Date Last Visa Was Issued:

Visa Number:

/червен номер в дясната част на визата, под Expiration Date/

Are you applying for the same type of visa? Yes No

Are you applying in the same country where the visa above was issued and is this country your principal country of residence? Yes No

Have you been ten-printed? Yes No

/На този въпрос се отбелязва Yes само ако сте били на интервю за виза от 2008 нататък/

Has your U.S. Visa ever been lost or stolen? Yes No

If yes, enter the year it was stolen:

Has your U.S. Visa ever been cancelled or revoked? Yes No If Yes, please specify

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? Yes No

If Yes, please explain

U.S. Point of Contact Information (тук се попълват имената, адреса, телефона и мейла на работодателя. Не може да пишете пощенска кутия)

Organization Name:
U.S. Street Address:
City:
State:
ZIP Code:
Phone Number:
Email Address:

Family Information: Relatives

Father's Full Name and Date of Birth

Surnames:

Given Names:

Date of Birth:

/Изписвайте датите във формат DDMMMYYYY/

Is your father in the U.S.? Yes No If yes, please type his status there

Mother's Full Name and Date of Birth

Surnames:

Given Names:

Date of Birth:

/Изписвайте датите във формат DDMMMYYYY/

Is your mother in the U.S.? Yes No

If yes, please type his status there

Do you have any immediate relatives, not including parents, in the United States? Yes No

If yes, please specify

Do you have any other relatives in the United States? Yes No

If yes, please specify

Present Work/Education/Training Information

Present School Name:

School address:

Street Address:

/Изписвайте адреса без никакви препинателни знаци и символи/

City:

State/Province:

Postal Zone/ZIP Code:

Country:

Briefly describe your duties: Моля напишете: Student. For SWT I will be a ..., като на мястото на многоточието отбележите позицията, на която ще работите, например housekeeper.

Previous Work/Education/Training Information
NOTE: Provide your employment information for the last five years, if applicable. Ако имате повече предишни работодатели, моля копирайте въпроси от 103 до 116 и ги попълнете за всеки един.

Were you previously employed? Yes No

/Тук отбелязвате Yes само ако сте работили на трудов договор! Ако сте, попълнете всички следващи въпроси до 117!/

If yes:

Employer Name:

/Изпишете името на фирмата без никакви символи/

Employer Street Address:

/Изписвайте адреса без никакви препинателни знаци и символи/

City:

State/Province:

Postal Zone/ZIP Code:

Country:

Telephone Number:

/Изписвайте номера във формат +359XXXXXXXXX/

Job Title:

Supervisor's Surname:

Supervisor's Given Names:

Employment Date From:

/Изписвайте датите във формат DDMMMYYYY/

Employment Date To:

/Изписвайте датите във формат DDMMMYYYY/

Briefly describe your duties:

Have you attended any educational institution other than elementary schools?

/Отбележете пълна информация за гимназията, която сте посещавали, както и други университети, ако сте учили в такива!/

Yes X No

If yes:

Name of Institution:
Street Address (Line 1)

/Изписвайте адреса без никакви препинателни знаци и символи/

City:
State/ Province:
Postal Zone/ ZIP Code:
Country:
Course of Study:
Date of Attendance from:
Date of Attendance to:
Name of Institution (2):
Street Address (Line 1)

/Изписвайте адреса без никакви препинателни знаци и символи/

City:
State/ Province:
Postal Zone/ ZIP Code:
Country:
Course of Study:
Date of Attendance from:
Date of Attendance to:
Name of Institution (3):
Street Address (Line 1)

/Изписвайте адреса без никакви препинателни знаци и символи/

City:
State/ Province:
Postal Zone/ ZIP Code:
Country:
Course of Study:
Date of Attendance from:
Date of Attendance to:
Do you belong to a clan or tribe? Yes No
Have you traveled to any countries within the last five years? Yes No

If yes please list all the countries visited and give the year of each visit.

Have you belonged to, contributed to, or worked for any professional, social or charitable organization? Yes No

If yes, please specify:

Do you have any specialized skills or training, including firearms explosives, nuclear biological or chemical experience? Yes No

If yes, please explain:

Have you ever served in the military? Yes No

If Yes, Give Name of Country, Branch of Service, Rank/Position, Military Specialty, and Dates of

Service.

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? Yes No

If yes, please explain:

Security and Background: Medical and Health Information

NOTE: Provide the following security and background information. Provide complete and accurate information to all questions that require an explanation. 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). Are any of the following applicable to you? While a YES answer does not automatically signify ineligibility for a visa, if you answer YES you may be required to personally appear before a consular officer.

Do you have a communicable disease of public health significance such as tuberculosis (TB)?

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 you ever been a drug abuser or addict?

Yes No
Security and Background: Criminal Information

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

Yes No

If yes, please explain:

Have you ever violated, or engaged in a conspiracy to violate, any law relating to controlled substances?

Yes No

If yes, please explain:

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?

Yes No

If yes, please explain:

Have you ever been involved in, or do you seek to engage in, money laundering?

Yes No

If yes, please explain:

Security and Background: Security Information

Do you seek to engage in espionage, sabotage, export control violations, or any other illegal activity while in the United States?

Yes No

If yes, please explain:

Do you seek to engage in terrorist activities while in the United States or have you ever engaged in terrorist activities?

Yes No

If yes, please explain:

Have you ever or do you intend to provide financial assistance or other support to terrorists or terrorist organizations?

Yes No

If yes, please explain:

Are you a member or representative of a terrorist organization?

Yes No

If yes, please explain:

Have you ever ordered, incited, committed, assisted, or otherwise participated in genocide?

Yes No

If yes, please explain:

Have you ever committed, ordered, incited, assisted, or otherwise participated in torture?

Yes No

If yes, please explain:

Have you committed, ordered, incited, assisted, or otherwise participated in extrajudicial killings, political killings, or other acts of violence?

Yes No

If yes, please explain:

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

If yes, please explain:

Security and Background: Immigration Law Violation Information

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?

Yes No

If yes, please explain:

Security and Background: Miscellaneous Information

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?

Yes No

If yes, please explain:

Have you voted in the United States in violation of any law or regulation?

Yes No

If yes, please explain:

Have you ever renounced United States citizenship for the purpose of avoiding taxation?

Yes No

If yes, please explain:

Additional Point of Contact Information

NOTE: You have indicated that you will be studying in some capacity while in the United States. List at least two contacts in your country of residence who can verify the information that you have provided on this application. Do not list immediate family members or other relatives. Postal office box numbers are unacceptable. Моля напишете информация за контакт на двама ваши приятели, които не са ви роднини и които няма да пътуват към Щатите това лято.

Surnames:

Given Names:

Street Address:

/Изписвайте адреса без никакви препинателни знаци и символи/

City:

State/Province:

Postal Zone/ZIP Code:

Country:

Telephone Number:

/Изписвайте номера във формат +359XXXXXXXXX/

Email Address:

Surnames:

Given Names:

Street Address:

/Изписвайте адреса без никакви препинателни знаци и символи/

City:

State/Province:
Postal Zone/ZIP Code:

Country:

Telephone Number:

/Изписвайте номера във формат +359XXXXXXXXX/

Email Address:

SEVIS Information

NOTE: You have indicated that the purpose of your trip to the U.S. is to be a student or exchange visitor. Provide the following information regarding the institution at which you intend to study.

SEVIS ID (Тук се попълва номерът на DS 2019. Ако не го знаете, оставете полето празно)

Do you intend to study in the U.S.? Yes No

Read the following information carefully before dating, signing and submitting the application.

Your signature certifies that you have read and understood the questions in this application and that your answers are true and correct to the best of your knowledge and belief. The submission of an application containing any false or misleading statements may result in the permanent refusal of a visa or the denial of entry into the United States. All declarations made in this application are unsworn declarations made under penalty of perjury. (28 U.S.C. 1746).

The information that you have provided in your application and other information submitted with your application may be accessible to other government agencies having statutory or other lawful authority to use such information, including for law enforcement and immigration law enforcement purposes. The photograph that you provide with your application may be used for employment verification or other U.S. law purposes.

I certify under penalty of perjury under the laws of the United States of America that the foregoing is true and correct.

Signature: Date:

ДЕКЛАРАЦИЯ

Декларирам, че съм предоставил личните си данни за кандидатстване за американска виза доброволно и след като съм бил уведомен от “Юзит Калърс България” ООД относно последиците от непредоставянето на тези данни. Известни са ми целта и средствата за обработка на личните ми данни, кръгът от получатели и сферите на ползване, както и правото ми на достъп до данните и адреса на администратора. Запознат съм с изискванията към участниците, използващи он-лайн регистрация и отговарям на същите, като потвърждавам верността и истинността на предоставените от мен данни и информация във формуляр DS 160 Visa Application, изпратен до Юзит Калърс България ООД от личната ми електронна поща или предоставен от мен на служител на Юзит Калърс. Известна ми е отговорността по чл.308, чл.309 и чл.316 от Наказателния кодекс на Република България за съставяне на документ с невярно съдържание, преправяне на съдържание на документ или използване на документ с невярно съдържание.

Декларирам, че ми е известна отговорността по член 313, ал.1 и ал.3 от Наказателния кодекс, за потвърждаване на неистина или затаяване на истина в писмена декларация, съобщение или частен документ и изпратени по електронен път. Декларирам, че информацията, която предоставям, е с вярно и истинно съдържание, както и че съм едноличен автор на всички изявления, съдържащи се във формуляр DS 160 Visa Application, предоставен ми от Юзит Калърс България ООД.

Декларирам, че съм съгласен Юзит Калърс да попълни от мое име онлайн формуляр DS160 за кандидатстване за американска виза, на базата на предоставената от мен информация в този DS160 Visa Application.

Декларирам, че съм съгласен паспорта с визата ми да бъде получен и съхраняван в офис на “ЮЗИТ КАЛЪРС”.

Участник: (трите имена) Подпис:
DECLARATION

Hereby I declare, that I volunteer my personal information for American visa application, after being notified by Usit Colours Ltd. regarding the consequences of not doing so. I am aware of the purpose and the means for working with my personal information, the sphere of receivers and usage as well as of my right of access to this information and to the administrator address. I am aware of the requirements to the participants using the on-line registration and I meet the same requirements. I confirm the faithfulness and the truth of the data and information provided by myself in the DS 160 Visa Application, e-mailed to Usit Colours from my personal e-mail account or provided by me to Usit Colours’ employee. I am aware of the responsibility I face under articles 308, 309 and 316 of the Bulgarian Penal Code for creating a document with a fake content, modifying the content of a document or using a document with a fake content.

I declare that I am aware of the responsibility I face under article 313, paragraphs 1 and 3 of the Bulgarian Penal Code, for confirming of false statement or not writing a true statement in a written declaration, message or private documents sent in an electronic way. I declare that the information I volunteer is with a true and real content as well as that I am a one-man author of all statements in the DS160 Visa Application, provided by Usit Colours.

I declare, that I agree Usit Colours to complete on my behalf the American visa electronic application form DS160, based on the information, provided by me in this DS 160 Visa Application form.

I also declare that I agree my passport with my visa to be delivered at “USIT COLOURS” office.
PARTICIPANT: Signature:

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