Microsoft Word - DS-260-Exemplar

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DS-260
IV Application
SAMPLE

September 2025
SBU

Bureau of Consular
Affairs Consular Systems
and Technology

Sign In Page

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Sign In Page

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Sign In Page

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Summary Information Page
Example of a piVot case Summary page.

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Getting Started Page – Immigration Visa and Alien
Registration Application

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Personal Information 1 Page

Displayed for all applicants. Answered ‘No’ to the question “Have you ever used other names (i.e., maiden,
religious, professional, alias, etc.)?”.
Current Marital Status

Date of Birth

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Personal Information 1 Page

Displayed for all applicants. Answered ‘Yes’ to the question ‘Have you ever used other names (i.e., maiden,
religious, professional, aliases, etc.)?’.
Country/Region of Birth

See all options for "Country/Region of
Birth" on following page.

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Country/Region of Birth
Select One, AFGHANISTAN, ALBANIA, ALGERIA, AMERICAN SAMOA, ANDORRA, ANGOLA, ANGUILLA, ANTIGUA AND BARBUDA, ARGENTINA,
ARMENIA, ARUBA, AT SEA, AUSTRALIA, AUSTRIA, AZERBAIJAN, BAHAMAS, BAHRAIN, BANGLADESH, BARBADOS, BELARUS, BELGIUM, BELIZE,
BENIN, BERMUDA, BHUTAN, BOLIVIA, BONAIRE, BOSNIA-HERZEGOVINA, BOTSWANA, BRAZIL, BRITISH INDIAN OCEAN TERRITORY, BRUNEI,
BULGARIA, BURKINA FASO, BURMA, BURUNDI, CAMBODIA, CAMEROON, CANADA, CABO VERDE, CAYMAN ISLANDS, CENTRAL AFRICAN
REPUBLIC, CHAD, CHILE, CHINA, CHRISTMAS ISLAND, COCOS KEELING ISLANDS, COLOMBIA, COMOROS, CONGO, DEMOCRATIC REPUBLIC OF
THE, CONGO, REPUBLIC OF THE, COOK ISLANDS, COSTA RICA, COTE D`IVOIRE, CROATIA, CUBA, CURACAO, CYPRUS, CZECH REPUBLIC,
DENMARK, DJIBOUTI, DOMINICA, DOMINICAN REPUBLIC, ECUADOR, EGYPT, EL SALVADOR, EQUATORIAL GUINEA, ERITREA, ESTONIA,
ESWATINI, ETHIOPIA, FALKLAND ISLANDS, FAROE ISLANDS, FIJI, FINLAND, FRANCE, FRENCH GUIANA, FRENCH POLYNESIA, FRENCH
SOUTHERN AND ANTARCTIC TERRITORIES, GABON, GAMBIA, THE, GAZA STRIP, GEORGIA, GERMANY, GHANA, GIBRALTAR, GREECE,
GREENLAND, GRENADA, GUADELOUPE, GUAM, GUATEMALA, GUINEA, GUINEA - BISSAU, GUYANA, HAITI, HEARD AND MCDONALD ISLANDS,
HOLY SEE (VATICAN CITY), HONDURAS, HONG KONG BNO, HONG KONG SAR, HOWLAND ISLAND, HUNGARY, ICELAND, IN THE AIR, INDIA,
INDONESIA, IRAN, IRAQ, IRELAND, ISRAEL, ITALY, JAMAICA, JAPAN, JERUSALEM, JORDAN, KAZAKHSTAN, KENYA, KIRIBATI, KOREA,
DEMOCRATIC REPUBLIC OF (NORTH), KOREA, REPUBLIC OF (SOUTH), KOSOVO, KUWAIT, KYRGYZSTAN, LAOS, LATVIA, LEBANON, LESOTHO,
LIBERIA, LIBYA, LIECHTENSTEIN, LITHUANIA, LUXEMBOURG, MACAU, MADAGASCAR, MALAWI, MALAYSIA, MALDEN ISLAND, MALDIVES,
MALI, MALTA, MARSHALL ISLANDS, MARTINIQUE, MAURITANIA, MAURITIUS, MAYOTTE, MEXICO - AGUASCALIENTES, MEXICO - BAJA
CALIFORNIA NORTE, MEXICO - BAJA CALIFORNIA SUR, MEXICO - CAMPECHE, MEXICO - CHIAPAS, MEXICO - CHIHUAHUA, MEXICO COAHUILA, MEXICO - COLIMA, MEXICO - DISTRITO FEDERAL, MEXICO - DURANGO, MEXICO - GUANAJUATO, MEXICO - GUERRERO, MEXICO HIDALGO, MEXICO - JALISCO, MEXICO - MICHOACAN, MEXICO - MORELOS, MEXICO - NAYARIT, MEXICO - NUEVO LEON, MEXICO - OAXACA,
MEXICO - PUEBLA, MEXICO - QUERETARO, MEXICO - QUINTANA ROO, MEXICO - SAN LUIS POTOSI, MEXICO - SINALOA, MEXICO - SONORA,
MEXICO - STATE OF MEXICO, MEXICO - TABASCO, MEXICO - TAMAULIPAS, MEXICO - TLAXCALA, MEXICO - VERACRUZ, MEXICO - YUCATAN,
MEXICO - ZACATECAS, MICRONESIA, MIDWAY ISLANDS, MOLDOVA, MONACO, MONGOLIA, MONTENEGRO, MONTSERRAT, MOROCCO,
MOZAMBIQUE, NAMIBIA, NAURU, NEPAL, NETHERLANDS, NEW CALEDONIA, NEW ZEALAND, NICARAGUA, NIGER, NIGERIA, NIUE, NORFOLK
ISLAND, NORTH MACEDONIA, NORTH MARIANA ISLANDS, NORTHERN IRELAND, NORWAY, OMAN, PAKISTAN, PALAU, PALMYRA ATOLL,
PANAMA, PAPUA NEW GUINEA, PARAGUAY, PERU, PHILIPPINES, PITCAIRN ISLANDS, POLAND, PORTUGAL, PUERTO RICO, QATAR, REUNION,
ROMANIA, RUSSIA, RWANDA, SABA ISLAND, SAINT MARTIN, SAMOA, SAN MARINO, SAO TOME AND PRINCIPE, SAUDI ARABIA, SENEGAL,
SERBIA, SEYCHELLES, SIERRA LEONE, SINGAPORE, SINT MAARTEN, SLOVAKIA, SLOVENIA, SOLOMON ISLANDS, SOMALIA, SOUTH AFRICA,
SOUTH GEORGIA AND THE SOUTH SANDWICH ISLAND, SOUTH SUDAN, SPAIN, SRI LANKA, ST. BARTHELEMY, ST. EUSTATIUS, ST. HELENA, ST.
KITTS AND NEVIS, ST. LUCIA, ST. PIERRE AND MIQUELON, ST. VINCENT AND THE GRENADINES, SUDAN, SURINAME, SVALBARD, SWEDEN,
SWITZERLAND, SYRIA, TAIWAN, TAJIKISTAN, TANZANIA, THAILAND, TIMOR-LESTE, TOGO, TOKELAU, TONGA, TRINIDAD AND TOBAGO,
TUNISIA, TURKEY, TURKMENISTAN, TURKS AND CAICOS ISLANDS, TUVALU, UGANDA, UKRAINE, UNITED ARAB EMIRATES, UNITED
KINGDOM, UNITED STATES OF AMERICA, URUGUAY, UZBEKISTAN, VANUATU, VENEZUELA, VIETNAM, VIRGIN ISLANDS (U.S.), VIRGIN
ISLANDS, BRITISH, WAKE ISLAND, WALLIS AND FUTUNA ISLANDS, WEST BANK, WESTERN SAHARA, YEMEN, ZAMBIA, ZIMBABWE

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Personal Information 2 Page

Displayed for all applicants. Answered “Passport” for “Document Type”. Answered ‘No’ to all
remaining questions.

Document Type

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Country/Region of Origin (Nationality):
Select One, AFGHANISTAN, ALBANIA, ALGERIA, ANDORRA, ANGOLA, ANGUILLA, ANTIGUA AND BARBUDA, ARGENTINA,
ARMENIA, ARUBA, AUSTRALIA, AUSTRIA, AZERBAIJAN, BAHAMAS, BAHRAIN, BANGLADESH, BARBADOS, BELARUS, BELGIUM,
BELIZE, BENIN, BERMUDA, BHUTAN, BOLIVIA, BOSNIA-HERZEGOVINA, BOTSWANA, BRAZIL, BRITISH INDIAN OCEAN
TERRITORY, BRUNEI, BULGARIA, BURKINA FASO, BURMA, BURUNDI, CAMBODIA, CAMEROON, CANADA, CABO VERDE,
CAYMAN ISLANDS, CENTRAL AFRICAN REPUBLIC, CHAD, CHILE, CHINA, COLOMBIA, COMOROS, CONGO, DEMOCRATIC
REPUBLIC OF THE, CONGO, REPUBLIC OF THE, COSTA RICA, COTE D`IVOIRE, CROATIA, CUBA, CYPRUS, CZECH REPUBLIC,
DENMARK, DJIBOUTI, DOMINICA, DOMINICAN REPUBLIC, ECUADOR, EGYPT, EL SALVADOR, EQUATORIAL GUINEA, ERITREA,
ESTONIA, ESWATINI, ETHIOPIA, FIJI, FINLAND, FRANCE, GABON, GAMBIA, THE, GEORGIA, GERMANY, GHANA, GIBRALTAR,
GREECE, GRENADA, GUATEMALA, GUINEA, GUINEA - BISSAU, GUYANA, HAITI, HOLY SEE (VATICAN CITY), HONDURAS, HONG
KONG BNO, HONG KONG SAR, HUNGARY, ICELAND, INDIA, INDONESIA, IRAN, IRAQ, IRELAND, ISRAEL, ITALY, JAMAICA, JAPAN,
JORDAN, KAZAKHSTAN, KENYA, KIRIBATI, KOREA, DEMOCRATIC REPUBLIC OF (NORTH), KOREA, REPUBLIC OF (SOUTH),
KOSOVO, KUWAIT, KYRGYZSTAN, LAOS, LATVIA, LEBANON, LESOTHO, LIBERIA, LIBYA, LIECHTENSTEIN, LITHUANIA,
LUXEMBOURG, MACAU, MADAGASCAR, MALAWI, MALAYSIA, MALDIVES, MALI, MALTA, MARSHALL ISLANDS, MAURITANIA,
MAURITIUS, MEXICO, MICRONESIA, MOLDOVA, MONACO, MONGOLIA, MONTENEGRO, MONTSERRAT, MOROCCO,
MOZAMBIQUE, NAMIBIA, NAURU, NEPAL, NETHERLANDS, NEW ZEALAND, NICARAGUA, NIGER, NIGERIA, NORTH MACEDONIA,
NORWAY, OMAN, PAKISTAN, PALAU, PALESTINIAN AUTHORITY, PANAMA, PAPUA NEW GUINEA, PARAGUAY, PERU,
PHILIPPINES, PITCAIRN ISLANDS, POLAND, PORTUGAL, QATAR, ROMANIA, RUSSIA, RWANDA, SAMOA, SAN MARINO, SAO TOME
AND PRINCIPE, SAUDI ARABIA, SENEGAL, SERBIA, SEYCHELLES, SIERRA LEONE, SINGAPORE, SLOVAKIA, SLOVENIA, SOLOMON
ISLANDS, SOMALIA, SOUTH AFRICA, SOUTH SUDAN, SPAIN, SRI LANKA, ST. HELENA, ST. KITTS AND NEVIS, ST. LUCIA, ST.
VINCENT AND THE GRENADINES, STATELESS, SUDAN, SURINAME, SWEDEN, SWITZERLAND, SYRIA, TAIWAN, TAJIKISTAN,
TANZANIA, THAILAND, TIMOR-LESTE, TOGO, TONGA, TRINIDAD AND TOBAGO, TUNISIA, TURKEY, TURKMENISTAN, TURKS
AND CAICOS ISLANDS, TUVALU, UGANDA, UKRAINE, UNITED ARAB EMIRATES, UNITED KINGDOM, URUGUAY, UZBEKISTAN,
VANUATU, VENEZUELA, VIETNAM, VIRGIN ISLANDS, BRITISH, WALLIS AND FUTUNA ISLANDS, WESTERN SAHARA, YEMEN,
ZAMBIA, ZIMBABWE.
Country/Authority that Issued document:
Select One, AFGHANISTAN, ALBANIA, ALGERIA, AMERICAN SAMOA, ANDORRA, ANGOLA, ANGUILLA, ANTIGUA AND BARBUDA,
ARGENTINA, ARMENIA, ARUBA, AUSTRALIA, AUSTRIA, AZERBAIJAN, BAHAMAS, BAHRAIN, BANGLADESH, BARBADOS, BELARUS,
BELGIUM, BELIZE, BENIN, BERMUDA, BHUTAN, BOLIVIA, BOSNIA-HERZEGOVINA, BOTSWANA, BRAZIL, BRITISH INDIAN OCEAN
TERRITORY, BRUNEI, BULGARIA, BURKINA FASO, BURMA, BURUNDI, CAMBODIA, CAMEROON, CANADA, CABO VERDE, CAYMAN
ISLANDS, CENTRAL AFRICAN REPUBLIC, CHAD, CHILE, CHINA, COLOMBIA, COMOROS, CONGO, DEMOCRATIC REPUBLIC OF THE,
CONGO, REPUBLIC OF THE, COSTA RICA, COTE D`IVOIRE, CROATIA, CUBA, CYPRUS, CZECH REPUBLIC, DENMARK, DJIBOUTI,
DOMINICA, DOMINICAN REPUBLIC, ECUADOR, EGYPT, EL SALVADOR, EQUATORIAL GUINEA, ERITREA, ESTONIA, ESWATINI,
ETHIOPIA, FIJI, FINLAND, FRANCE, GABON, GAMBIA, THE, GEORGIA, GERMANY, GHANA, GIBRALTAR, GREECE, GRENADA,
GUATEMALA, GUINEA, GUINEA - BISSAU, GUYANA, HAITI, HEARD AND MCDONALD ISLANDS, HOLY SEE (VATICAN CITY),
HONDURAS, HONG KONG SAR, HONG KONG, BRITISH CONSULATE GENERAL, HUNGARY, ICELAND, INDIA, INDONESIA, IRAN,
IRAQ, IRELAND, ISRAEL, ITALY, JAMAICA, JAPAN, JORDAN, KAZAKHSTAN, KENYA, KIRIBATI, KOREA, DEMOCRATIC REPUBLIC OF
(NORTH), KOREA, REPUBLIC OF (SOUTH), KOSOVO, KUWAIT, KYRGYZSTAN, LAOS, LATVIA, LEBANON, LESOTHO, LIBERIA, LIBYA,
LIECHTENSTEIN, LITHUANIA, LUXEMBOURG, MACAU, MADAGASCAR, MALAWI, MALAYSIA, MALDIVES, MALI, MALTA,
MARSHALL ISLANDS, MARTINIQUE, MAURITANIA, MAURITIUS, MEXICO, MICRONESIA, MOLDOVA, MONACO, MONGOLIA,
MONTENEGRO, MONTSERRAT, MOROCCO, MOZAMBIQUE, NAMIBIA, NAURU, NEPAL, NETHERLANDS, NEW ZEALAND,
NICARAGUA, NIGER, NIGERIA, NORTH MACEDONIA, NORWAY, OMAN, PAKISTAN, PALAU, PALESTINIAN AUTHORITY, PANAMA,
PAPUA NEW GUINEA, PARAGUAY, PERU, PHILIPPINES, PITCAIRN ISLANDS, POLAND, PORTUGAL, QATAR, ROMANIA, RUSSIA,
RWANDA, SAMOA, SAN MARINO, SAO TOME AND PRINCIPE, SAUDI ARABIA, SENEGAL, SERBIA, SEYCHELLES, SIERRA LEONE,
SINGAPORE, SLOVAKIA, SLOVENIA, SOLOMON ISLANDS, SOMALIA, SOUTH AFRICA, SOUTH SUDAN, SPAIN, SRI LANKA, ST.
HELENA, ST. KITTS AND NEVIS, ST. LUCIA, ST. VINCENT AND THE GRENADINES, STATUS NEUTRAL TRAVEL DOCUMENT, SUDAN,
SURINAME, SWEDEN, SWITZERLAND, SYRIA, TAIWAN, TAJIKISTAN, TANZANIA, THAILAND, TIMOR-LESTE, TOGO, TONGA,
TRINIDAD AND TOBAGO, TUNISIA, TURKEY, TURKMENISTAN, TURKS AND CAICOS ISLANDS, TUVALU, UGANDA, UKRAINE,
UNITED ARAB EMIRATES, UNITED KINGDOM, UNITED NATIONS LAISSEZ-PASSER, URUGUAY, UZBEKISTAN, VANUATU,
VENEZUELA, VIETNAM, VIRGIN ISLANDS, BRITISH, WALLIS AND FUTUNA ISLANDS, YEMEN, ZAMBIA, ZIMBABWE.

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Personal Information 2 Page

Displayed for all applicants. Answered “Other Travel Document” for “Document Type”’. Answered ‘Yes’ to
the questions ‘Do you hold or have you held any nationality other than the one indicated in question
above?’ and ‘answer “Yes” to the question “Have you owned any other passports within the past fifteen
years that have not already been mentioned above?".

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Personal Information 2 Page

Other Country/Region of Origin:
Select One, AFGHANISTAN, ALBANIA, ALGERIA, ANDORRA, ANGOLA, ANGUILLA, ANTIGUA AND
BARBUDA, ARGENTINA, ARMENIA, ARUBA, AUSTRALIA, AUSTRIA, AZERBAIJAN, BAHAMAS, BAHRAIN,
BANGLADESH, BARBADOS, BELARUS, BELGIUM, BELIZE, BENIN, BERMUDA, BHUTAN, BOLIVIA,
BOSNIA-HERZEGOVINA, BOTSWANA, BRAZIL, BRITISH INDIAN OCEAN TERRITORY, BRUNEI,
BULGARIA, BURKINA FASO, BURMA, BURUNDI, CAMBODIA, CAMEROON, CANADA, CABO VERDE,
CAYMAN ISLANDS, CENTRAL AFRICAN REPUBLIC, CHAD, CHILE, CHINA, COLOMBIA, COMOROS,
CONGO, DEMOCRATIC REPUBLIC OF THE, CONGO, REPUBLIC OF THE, COSTA RICA, COTE D`IVOIRE,
CROATIA, CUBA, CYPRUS, CZECH REPUBLIC, DENMARK, DJIBOUTI, DOMINICA, DOMINICAN
REPUBLIC, ECUADOR, EGYPT, EL SALVADOR, EQUATORIAL GUINEA, ERITREA, ESTONIA, ESWATINI,
ETHIOPIA, FIJI, FINLAND, FRANCE, GABON, GAMBIA, THE, GEORGIA, GERMANY, GHANA, GIBRALTAR,
GREECE, GRENADA, GUATEMALA, GUINEA, GUINEA - BISSAU, GUYANA, HAITI, HOLY SEE (VATICAN
CITY), HONDURAS, HONG KONG BNO, HONG KONG SAR, HUNGARY, ICELAND, INDIA, INDONESIA,
IRAN, IRAQ, IRELAND, ISRAEL, ITALY, JAMAICA, JAPAN, JORDAN, KAZAKHSTAN, KENYA, KIRIBATI,
KOREA, DEMOCRATIC REPUBLIC OF (NORTH), KOREA, REPUBLIC OF (SOUTH), KOSOVO, KUWAIT,
KYRGYZSTAN, LAOS, LATVIA, LEBANON, LESOTHO, LIBERIA, LIBYA, LIECHTENSTEIN, LITHUANIA,
LUXEMBOURG, MACAU, MADAGASCAR, MALAWI, MALAYSIA, MALDIVES, MALI, MALTA, MARSHALL
ISLANDS, MAURITANIA, MAURITIUS, MEXICO, MICRONESIA, MOLDOVA, MONACO, MONGOLIA,
MONTENEGRO, MONTSERRAT, MOROCCO, MOZAMBIQUE, NAMIBIA, NAURU, NEPAL, NETHERLANDS,
NEW ZEALAND, NICARAGUA, NIGER, NIGERIA, NORTH MACEDONIA, NORWAY, OMAN, PAKISTAN,
PALAU, PALESTINIAN AUTHORITY, PANAMA, PAPUA NEW GUINEA, PARAGUAY, PERU, PHILIPPINES,
PITCAIRN ISLANDS, POLAND, PORTUGAL, QATAR, ROMANIA, RUSSIA, RWANDA, SAMOA, SAN
MARINO, SAO TOME AND PRINCIPE, SAUDI ARABIA, SENEGAL, SERBIA, SEYCHELLES, SIERRA LEONE,
SINGAPORE, SLOVAKIA, SLOVENIA, SOLOMON ISLANDS, SOMALIA, SOUTH AFRICA, SOUTH SUDAN,
SPAIN, SRI LANKA, ST. HELENA, ST. KITTS AND NEVIS, ST. LUCIA, ST. VINCENT AND THE
GRENADINES, SUDAN, SURINAME, SWEDEN, SWITZERLAND, SYRIA, TAIWAN, TAJIKISTAN, TANZANIA,
THAILAND, TIMOR-LESTE, TOGO, TONGA, TRINIDAD AND TOBAGO, TUNISIA, TURKEY,
TURKMENISTAN, TURKS AND CAICOS ISLANDS, TUVALU, UGANDA, UKRAINE, UNITED ARAB
EMIRATES, UNITED KINGDOM, UNITED STATES OF AMERICA, URUGUAY, UZBEKISTAN, VANUATU,
VENEZUELA, VIETNAM, VIRGIN ISLANDS, BRITISH, WALLIS AND FUTUNA ISLANDS, WESTERN
SAHARA, YEMEN, ZAMBIA, ZIMBABWE.
Country/Region of Issuance: Same options as "Country/Authority that Issued Document" dropdown.

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Present and Previous Address Information Page

Displayed for all applicants. All questions answered ‘No’. Please note sections added for Additional
Telephone and Email Address. Additional field for Social Media and Other Social Media.

Social Media Provider/Platform

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Country/Region:
Select One, AFGHANISTAN, ALBANIA, ALGERIA, AMERICAN SAMOA, ANDORRA, ANGOLA, ANGUILLA, ANTIGUA AND
BARBUDA, ARGENTINA, ARMENIA, ARUBA, AUSTRALIA, AUSTRIA, AZERBAIJAN, BAHAMAS, BAHRAIN, BANGLADESH,
BARBADOS, BELARUS, BELGIUM, BELIZE, BENIN, BERMUDA, BHUTAN, BOLIVIA, BONAIRE, BOSNIA-HERZEGOVINA,
BOTSWANA, BRAZIL, BRITISH INDIAN OCEAN TERRITORY, BRUNEI, BULGARIA, BURKINA FASO, BURMA, BURUNDI,
CAMBODIA, CAMEROON, CANADA, CABO VERDE, CAYMAN ISLANDS, CENTRAL AFRICAN REPUBLIC, CHAD, CHILE, CHINA,
CHRISTMAS ISLAND, COCOS KEELING ISLANDS, COLOMBIA, COMOROS, CONGO, DEMOCRATIC REPUBLIC OF THE, CONGO,
REPUBLIC OF THE, COOK ISLANDS, COSTA RICA, COTE D`IVOIRE, CROATIA, CUBA, CURACAO, CYPRUS, CZECH REPUBLIC,
DENMARK, DJIBOUTI, DOMINICA, DOMINICAN REPUBLIC, ECUADOR, EGYPT, EL SALVADOR, EQUATORIAL GUINEA,
ERITREA, ESTONIA, ESWATINI, ETHIOPIA, FALKLAND ISLANDS, FAROE ISLANDS, FIJI, FINLAND, FRANCE, FRENCH GUIANA,
FRENCH POLYNESIA, FRENCH SOUTHERN AND ANTARCTIC TERRITORIES, GABON, GAMBIA, THE, GAZA STRIP, GEORGIA,
GERMANY, GHANA, GIBRALTAR, GREECE, GREENLAND, GRENADA, GUADELOUPE, GUAM, GUATEMALA, GUINEA, GUINEA BISSAU, GUYANA, HAITI, HEARD AND MCDONALD ISLANDS, HOLY SEE (VATICAN CITY), HONDURAS, HONG KONG,
HOWLAND ISLAND, HUNGARY, ICELAND, INDIA, INDONESIA, IRAN, IRAQ, IRELAND, ISRAEL, ITALY, JAMAICA, JAPAN,
JERUSALEM, JORDAN, KAZAKHSTAN, KENYA, KIRIBATI, KOREA, DEMOCRATIC REPUBLIC OF (NORTH), KOREA, REPUBLIC OF
(SOUTH), KOSOVO, KUWAIT, KYRGYZSTAN, LAOS, LATVIA, LEBANON, LESOTHO, LIBERIA, LIBYA, LIECHTENSTEIN,
LITHUANIA, LUXEMBOURG, MACAU, MADAGASCAR, MALAWI, MALAYSIA, MALDEN ISLAND, MALDIVES, MALI, MALTA,
MARSHALL ISLANDS, MARTINIQUE, MAURITANIA, MAURITIUS, MAYOTTE, MEXICO, MICRONESIA, MIDWAY ISLANDS,
MOLDOVA, MONACO, MONGOLIA, MONTENEGRO, MONTSERRAT, MOROCCO, MOZAMBIQUE, NAMIBIA, NAURU, NEPAL,
NETHERLANDS, NEW CALEDONIA, NEW ZEALAND, NICARAGUA, NIGER, NIGERIA, NIUE, NORFOLK ISLAND, NORTH
MACEDONIA, NORTH MARIANA ISLANDS, NORTHERN IRELAND, NORWAY, OMAN, PAKISTAN, PALAU, PALMYRA ATOLL,
PANAMA, PAPUA NEW GUINEA, PARAGUAY, PERU, PHILIPPINES, PITCAIRN ISLANDS, POLAND, PORTUGAL, PUERTO RICO,
QATAR, REUNION, ROMANIA, RUSSIA, RWANDA, SABA ISLAND, SAINT MARTIN, SAMOA, SAN MARINO, SAO TOME AND
PRINCIPE, SAUDI ARABIA, SENEGAL, SERBIA, SEYCHELLES, SIERRA LEONE, SINGAPORE, SINT MAARTEN, SLOVAKIA,
SLOVENIA, SOLOMON ISLANDS, SOMALIA, SOUTH AFRICA, SOUTH GEORGIA AND THE SOUTH SANDWICH ISLAND, SOUTH
SUDAN, SPAIN, SRI LANKA, ST. EUSTATIUS, ST. HELENA, ST. KITTS AND NEVIS, ST. LUCIA, ST. PIERRE AND MIQUELON, ST.
VINCENT AND THE GRENADINES, SUDAN, SURINAME, SVALBARD, SWEDEN, SWITZERLAND, SYRIA, TAIWAN, TAJIKISTAN,
TANZANIA, THAILAND, TIMOR-LESTE, TOGO, TOKELAU, TONGA, TRINIDAD AND TOBAGO, TUNISIA, TURKEY,
TURKMENISTAN, TURKS AND CAICOS ISLANDS, TUVALU, UGANDA, UKRAINE, UNITED ARAB EMIRATES, UNITED
KINGDOM, UNITED STATES OF AMERICA, URUGUAY, UZBEKISTAN, VANUATU, VENEZUELA, VIETNAM, VIRGIN ISLANDS
(U.S.), VIRGIN ISLANDS, BRITISH, WAKE ISLAND, WALLIS AND FUTUNA ISLANDS, WEST BANK, WESTERN SAHARA, YEMEN,
ZAMBIA, ZIMBABWE.

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Present and Previous Address Information Page
Displayed for all applicants. All questions answered ‘Yes’. "Facebook" selected for "Social Media
Provider/Platform". Please note sections added for Additional Telephone, Email Address, Social Media,
and Other Social Media.

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Page Continued

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Mailing and Permanent Address Page

Displayed for all applicants who do not list “United States of America” as their Present Address
Country/Region. All questions answered ‘Yes’.

State

See full list below:
Select one, ALABAMA, ALASKA, AMERICAN
SAMOA, ARIZONA, ARKANSAS,
CALIFORNIA, COLORADO, CONNECTICUT,
DELAWARE, DISTRICT OF COLUMBIA,
FLORIDA, GEORGIA, GUAM, HAWAII,
IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS,
KENTUCKY, LOUISIANA, MAINE,
MARYLAND, MASSACHUSETTS,
MICHIGAN, MINNESOTA, MISSISSIPPI,
MISSOURI, MONTANA, NEBRASKA,
NEVADA, NEW HAMPSHIRE, NEW JERSEY,
NEW MEXICO, NEW YORK, NORTH
CAROLINA, NORTH DAKOTA, NORTHERN
MARIANA ISLANDS, OHIO, OKLAHOMA,
OREGON, PENNSYLVANIA, PUERTO RICO,
RHODE ISLAND, SOUTH CAROLINA,
SOUTH DAKOTA, TENNESSEE, TEXAS,
UTAH, VERMONT, VIRGIN ISLANDS,
VIRGINIA, WASHINGTON, WEST VIRGINIA,
WISCONSIN, WYOMING.

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Mailing and Permanent Address Page

Displayed for all applicants who do not list “United States of America” as their Present Address
Country/Region.. All questions answered ‘No’.

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20

Mailing and Permanent Address

Displayed for all applicants who list “United States of America” as their Present Address Country/Region. .
All questions answered ‘Yes’.

21

Mailing and Permanent Address Page

Displayed for all applicants who list “United States of America” as their Present Address
Country/Region. Answered ‘No’ to the question ‘Is this address where you want your Permanent
Residence Card (Green Card) mailed?’.

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Family Information: Parents Page
Displayed for all applicants. Answers to all questions are “Yes”.

23

Family Information: Parents Page
Displayed for all applicants. Answers to all questions are “No”.

24

Family Information: Parents Page

Displayed for all applicants. Answered ‘Do Not Know’ to the questions ‘Surname’ and ‘Given Name’.

25

Family Information: Spouse or Civil/Domestic Partner Page
Displayed for applicants who indicate they are currently married or separated. Answered ‘No’ to the
question ‘Is your spouse or civil/domestic partner applying for a U.S. immigrant visa with you?’.

Spouse or Civil/Domestic Partner's Address

Occupation

Drop down options for
"Nationality" are listed on
page 11.

26

Family Information: Spouse or Civil/Domestic Partner Page
Displayed for applicants who indicate they are currently married or separated. Answered ‘Yes’ to the question
‘Is your spouse or civil/domestic partner applying for a U.S. immigrant visa with you?’.

27

Family Information: Spouse or Civil/Domestic Partner Page
Displayed for applicants who indicate they are currently married or separated. Selected ‘Same as Present
Address’ and ‘Not Employed’ for ‘Occupation’.

28

Family Information: Spouse or Civil/Domestic Partner Page
Displayed for applicants who indicate they are currently married or separated. Selected ‘Other (Specify
Address)’ for ‘Spouse or Civil/Domestic Partner's Address’ and ‘Not Employed’ for ‘Occupation’.

29

Family Information: Previous Spouse or Civil/
Domestic Partner Page

Displayed for all applicants. Answered ‘No’ to the question ‘Do you have any previous spouses or civil/
domestic partners?’.

30

Family Information: Previous Spouse or Civil/Domestic Partner Page
Displayed for all applicants. Answered ‘Yes’ to the question ‘Do you have any previous spouses or civil/domestic partners?’.
Answered ‘Other’ to the question ‘How was your marriage terminated?’.

How was your marriage terminated?

31

Family Information: Children Page

Displayed for all applicants. Answered ‘No’ to the question ‘Do you have any children?’.

32

Family Information: Children Page
Displayed for all applicants. Answered ‘Yes’ to all questions

33

Family Information: Children Page

Displayed for all applicants. Answered ‘Yes’ to the question ‘Do you have any
children?’. Answered ‘No’ to the question ‘Is your child applying for a U.S. immigrant
visa with you?’.

34

Family Information: Siblings Page

Displayed for all applicants. Answered ‘No’ to the question ‘Do you have any siblings?’.

35

Family Information: Siblings Page

Displayed for all applicants. Answered ‘Yes’ to the question ‘Do you have any siblings?’.

36

Previous U.S. Travel Information Page
Displayed for all applicants. All questions are answered ‘No’.

37

Previous U.S. Travel Information Page
Displayed for all applicants that answer ‘Yes’ for all questions.

Length of Stay

Visa Classification

Full list of "Visa Classification" options on following page.

38

Visa Classification
Select one, AMBASSADOR OR PUBLIC MINISTER (A1), CHILD OF AN A1 (A1), CAREER DIPLOMAT/CONSULAR OFFICER (A1), SPOUSE
OF AN A1 (A1), CHILD OF AN A2 (A2), FOREIGN OFFICIAL/EMPLOYEE (A2), SPOUSE OF AN A2 (A2), CHILD OF AN A3 (A3), PERSONAL
EMP. OF AN A1 OR A2 (A3), SPOUSE OF AN A3 (A3), BUSINESS & TOURISM (TEMPORARY VISITOR) (B1/B2), BUSINESS/
CONFERENCE (B1), TOURISM/MEDICAL TREATMENT (B2), BORDER CROSSING CARD (MEXICO ONLY) (BCC), CREWMEMBER IN
TRANSIT (C1/D), TRANSIT (C1), TRANSIT TO U.N. HEADQUARTERS (C2), CHILD OF A C3 (C3), PERSONAL EMP. OF A C3 (C3),
FOREIGN OFFICIAL IN TRANSIT (C3), SPOUSE OF A C3 (C3), NONCITIZEN IN TRANSIT TO LIGHTERING OPERATION (C4),
LIGHTERING CREW MEMBER IN TRANSIT (C4/D3), CNMI TEMPORARY WORKER (CW1), CHILD OF CW1 (CW2), SPOUSE OF CW1
(CW2), CREWMEMBER (D), LIGHTERING CREW MEMBER (D3), CHILD OF AN E1 (E1), EXECUTIVE/MGR/ESSENTIAL EMP (E1),
SPOUSE OF AN E1 (E1), TREATY TRADER (E1), CHILD OF AN E2 (E2), EXECUTIVE/MGR/ESSENTIAL EMP (E2), SPOUSE OF AN E2
(E2), TREATY INVESTOR (E2), CNMI LONG TERM INVESTOR (E2C), AUSTRALIAN IN SPEC. OCCUPATION (E3), CHILD OF AN E3
(E3D), SPOUSE OF AN E3 (E3D), RETURNING AUSTRALIAN IN A SPEC. OCCUPATION (E3R), STUDENT (F1), CHILD OF AN F1 (F2),
SPOUSE OF AN F1 (F2), COMMUTER STUDENT (F3), CHILD OF A G1 (G1), PRINCIPAL REPRESENTATIVE (G1), SPOUSE OF A G1
(G1), STAFF OF PRINCIPAL REPRESENTATIVE (G1), CHILD OF A G2 (G2), REPRESENTATIVE (G2), SPOUSE OF A G2 (G2), CHILD OF
A G3 (G3), NON-RECOGNIZED/-MEMBER COUNTRY REP(G3), SPOUSE OF A G3 (G3), CHILD OF AN G4 (G4), INTERNATIONAL ORG.
EMPLOYEE (G4), SPOUSE OF A G4 (G4), CHILD OF A G5 (G5), PERSONAL EMP. OF A G1, 2, 3, OR 4 (G5), SPOUSE OF A G5 (G5),
NURSES (H1A), SPECIALTY OCCUPATION (H1B), CHILEAN SPEC. OCCUPATION (H1B1), SINGAPOREAN SPEC. OCCUPATION
(H1B1), NURSE IN SHORTAGE AREA (H1C), AGRICULTURAL WORKER (H2A), NONAGRICULTURAL WORKER (H2B), TRAINEE (H3),
CHILD OF AN H (H4), SPOUSE OF AN H (H4), CHILD OF AN I (I), FOREIGN MEDIA REPRESENTATIVE (I), SPOUSE OF AN I (I),
EXCHANGE VISITOR (J1), CHILD OF A J1 (J2), SPOUSE OF A J1 (J2), FIANCÉ(E) OF A U.S. CITIZEN (K1), CHILD OF A K1 (K2), SPOUSE
OF A U.S. CITIZEN (K3), CHILD OF A K3 (K4), INTRACOMPANY TRANSFEREE (L1), CHILD OF A L1 (L2), SPOUSE OF A L1 (L2),
STUDENT (M1), CHILD OF M1 (M2), SPOUSE OF M1 (M2), COMMUTER STUDENT (M3), CHILD OF A N8 (N9), PARENT OF CERTAIN
SPECIAL IMMIGRANT (N8), CHILD OF NATO 1 (NATO1), PRINCIPAL REPRESENTATIVE (NATO1), SPOUSE OF NATO1 (NATO1), CHILD
OF NATO2 (NATO2), REPRESENTATIVE (NATO2), SPOUSE OF NATO2 (NATO2), CHILD OF NATO3 (NATO3), SPOUSE OF NATO3
(NATO3), CLERICAL STAFF (NATO3), CHILD OF NATO4 (NATO4), OFFICIAL (NATO4), SPOUSE OF NATO4 (NATO4), CHILD OF NATO5
(NATO5), EXPERT (NATO5), SPOUSE OF NATO5 (NATO5), CHILD OF NATO6 (NATO6), SPOUSE OF NATO6 (NATO6), CIVILIAN STAFF
(NATO6), CHILD OF NATO7 (NATO7), PERSONAL EMP. OF NATO1-NATO6 (NATO7), SPOUSE OF NATO7 (NATO7), EXTRAORDINARY
ABILITY (O1), ALIEN ACCOMPANYING/ASSISTING (O2), CHILD OF O1 OR O2 (O3), SPOUSE OF O1 OR O2 (O3), OTHER - IMMIGRANT
VISA, OTHER - NOT LISTED, INTERNATIONALLY RECOGNIZED ALIEN (P1), ARTIST/ENTERTAINER EXCHANGE PROG. (P2), ARTIST/
ENTERTAINER IN CULTURAL PROG. (P3), CHILD OF P1, P2 OR P3 (P4), SPOUSE OF P1, P2 OR P3 (P4), USCIS HUMANITARIAN
PAROLE (HPCIS), ICE HUMANITARIAN PAROLE (HPICE), USCIS SIGNIFICANT PUBLIC BENEFIT PAROLE (SBCIS), ICE SIGNIFICANT
PUBLIC BENEFIT PAROLE (SBICE), CULTURAL EXCHANGE VISITOR (Q1), RELIGIOUS WORKER (R1), CHILD OF R1 (R2), SPOUSE OF
R1 (R2), FAMILY MEMBER OF AN INFORMANT (S7), VICTIM OF TRAFFICKING (T1), SPOUSE OF T1 (T2), CHILD OF T1 (T3), PARENT
OF T1 (T4), SIBLING OF T1 (T5), ADULT/MINOR CHILD OF A DERIV BEN OF A T1 (T6), CHILD OF TN (TD), SPOUSE OF TN (TD), NAFTA
PROFESSIONAL (TN), VICTIM OF CRIME (U1), SPOUSE OF U1 (U2), CHILD OF U1 (U3), PARENT OF U1 (U4), SIBLING OF U1 (U5), LIFE
ACT - SPOUSE OF LPR (V1), LIFE ACT - CHILD OF LPR (V2), LIFE ACT - CHILD OF A V1 OR V2 (V3).

39

Present Work/Education/Training Information Page
Displayed for all applicants over the age of 14

40

Present Work/Education/Training Information Page
Displayed for all applicants over the age of 14. Primary Occupation and ‘In which occupation do you intend to work in
the U.S.?’ is ‘Agriculture’, ‘Business’, ‘Communications’, ‘Computer Science’, ‘Culinary/Food Services’, ‘Education’,
‘Engineering’, ‘Government’, ‘Homemaker’, ‘Legal Profession’, ‘Medical/Health’, ‘Military’, ‘Natural Science’, ‘Physical
Sciences’, ‘Religious Vocation’, ‘Research’, ‘Social Science’, or ‘Student’. Answer to ‘Do you have other
occupations?’ is ‘No’.

41

Present Work/Education/Training Information Page

Displayed for all applicants over the age of 14. Primary Occupation and ‘In which occupation do you intend to work
in the U.S.?’ is ‘Agriculture’, ‘Business’, ‘Communications’, ‘Computer Science’, ‘Culinary/Food Services’,
‘Education’, ‘Engineering’, ‘Government’, ‘Homemaker’, ‘Legal Profession’, ‘Medical/Health’, ‘Military’, ‘Natural
Science’, ‘Physical Sciences’, ‘Religious Vocation’, ‘Research’, ‘Social Science’, or ‘Student’. Answer to ‘Do you
have other occupations?’ is ‘Yes’ and ‘Other Occupation’ is not ‘Other’ or ‘Homemaker’.

42

Present Work/Education/Training Information Page

Displayed for all applicants. Primary Occupation and ‘In which occupation do you intend to work in the U.S.?’ is
‘Agriculture’, ‘Business’, ‘Communications’, ‘Computer Science’, ‘Culinary/Food Services’, ‘Education’, ‘Engineering’,
‘Government’, ‘Homemaker’, ‘Legal Profession’, ‘Medical/Health’, ‘Military’, ‘Natural Science’, ‘Physical Sciences’,
‘Religious Vocation’, ‘Research’, ‘Social Science’, or ‘Student’. Answer to ‘Do you have other occupations?’ is ‘Yes’
and ‘Other Occupation’ is ‘Homemaker’.

43

Present Work/Education/Training Information Page

Displayed for all applicants over the age of 14. Primary Occupation and ‘In which occupation do you intend to work in
the U.S.?’ is ‘Other’.

44

Present Work/Education/Training Information Page

Displayed for all applicants. Primary Occupation and ‘In which occupation do you intend to work in the U.S.?’ is ‘Not
Employed’.

45

Present Work/Education/Training Information Page
Displayed for all applicants over the age of 14. Primary Occupation and ‘In which occupation do you
intend to work in the U.S.?’ is ‘Homemaker’ or ‘Retired’.

46

Present Work/Education/Training Information Page

Displayed only for Diversity Visa (DV)
principal applicants when Primary
Occupation is not
“HOMEMAKER”,
“NOT EMPLOYED” or “STUDENT”.

47

Present Work/Education/Training Information Page

Displayed only for Diversity Visa (DV) principal
applicants when Primary Occupation is not
“HOMEMAKER”, “NOT EMPLOYED” or
“STUDENT”. Answer to “Do you have other
occupations?” is “Yes”.

48

Present Work/Education/Training Information Page

Displayed only for Diversity Visa (DV) principal
applicants when Primary Occupation is not
“HOMEMAKER”, “NOT EMPLOYED” or
“STUDENT”.
Answer to “Do you have
other
occupations?”
is
“Yes”. Other Occupation is “OTHER”.

49

Previous Work/Education/Training Information Page
Displayed for all applicants over the age of 14. The answer to both questions is ‘No’.

50

Previous Work/Education/Training Information Page
Displayed for all applicants over the age of 14.
The answer to both questions is ‘Yes’.

51

Previous Work/Education/Training Information Page

Displayed for all DV principal applicants who answer “Yes” to the first question and “No” to the other questions
on the page.

52

Previous Work/Education/Training Information Page
Displayed for all DV principal applicants who answer “Yes” to all questions on the page.

Highest Level of Education Completed

53

Additional Work/Education/Training/Travel Information Page
Displayed for all applicants. The answer to all questions is ‘No’.

54

Additional Work/Education/Training/Travel Information Page
Displayed for all applicants. The answer to all questions is ‘Yes’.

Person/Entity Who Paid for Trip:

55

Additional Work/Education/Training/Travel Information Page

Part 2

56

Petitioner Information Page
Displayed for all applicants.

Petitioner is my...

57

Petitioner Information Page

Displayed for all applicants. Answered ‘Father’ to ‘Petitioner is my’. The same questions display if
"Mother", "Brother", "Sister", "Spouse", "Child", Stepfather", "Stepmother", "Uncle", "Aunt", Grandparent",
or "In-Law" is selected.

58

Petitioner Information Page
Displayed for all applicants. Answered ‘Self’ to the question ‘Petitioner is my’.

59

Security and Background: Medical and Health
Information Page

Displayed for all applicants. Answers to questions are ‘No’.

60

Security and Background: Medical and Health
Information Page
Displayed for all applicants. Answers to questions are ‘Yes’.

61

Security and Background: Criminal Information Page
Displayed for all applicants. Answers to questions are ‘No’.

62

Security and Background: Criminal Information Page
Displayed for all applicants. Answers to questions are ‘Yes’.

63

Security and Background: Security Information 1 Page
Displayed for all applicants. Answers to questions are ‘No’.

64

Security and Background: Security Information 1 Page
Displayed for all applicants. Answers to questions are ‘Yes’.

65

Security and Background: Security Information 2 Page
Displayed for all applicants. Answers to questions are ‘No’.

66

Security and Background: Security Information 2 Page
Displayed for all applicants. Answers to questions are ‘Yes’.

67

Security and Background: Immigration Law Violation
Information 1 Page

Displayed for all applicants who answered "No" to "Have you ever been to the U.S.?" on the Previous
U.S. Travel page. Displayed when you answer ‘No’ for both questions.

.

68

Security and Background: Immigration Law Violation
Information 1 Page

Displayed for all applicants who answered "No" to "Have you ever been to the U.S.?" on the Previous U.S.
Travel page. Displayed when you answer ‘Yes’ for both questions.

69

Security and Background: Immigration Law Violation
Information 1 Page
Displayed for all applicants who answered ‘Yes’ to ‘Have you ever been to the U.S.?’ on the Previous U.S.
Travel Page. Answers to questions are ‘No’.

70

Security and Background: Immigration Law Violation
Information 1 Page
Displayed for all applicants who answered ‘Yes’ to ‘Have you ever been to the U.S.?’ on the Previous
U.S. Travel page. Answers to questions are ‘Yes’.
Part 1:

71

Security and Background: Immigration Law Violation
Information 1 Page

Part 2

72

Security and Background: Immigration Law Violation
Information 2 Page
Displayed for all applicants who answered ‘Yes’ to ‘Have you ever been to the U.S.?’ on the Previous U.S.
Travel page. Answers to questions are ‘No’.

73

Security and Background: Immigration Law Violation
Displayed for all applicants who answered ‘Yes’ to ‘Have you ever been to the U.S.?’ on the Previous U.S.
Travel page. Answers to questions are ‘Yes’.

74

Security and Background: Miscellaneous Information 1
Page
Displayed for all applicants. Answers to questions are ‘No’.

75

Security and Background: Miscellaneous Information 1
Page
Displayed for all applicants. Answers to questions are ‘Yes’.

76

Security and Background: Miscellaneous Information 2
Page
Displayed for all applicants. Answers to questions are ‘No’.

77

Security and Background: Miscellaneous Information 2
Page
Displayed for all applicants. Answers to questions are ‘Yes’.

78

Social Security Number Information Page

Displayed for all applicants. Answers to questions are ‘No’.

79

Social Security Number Information Page
Displayed for all applicants. Answers to questions are ‘Yes’.

80

Social Security Number Information Page

Displayed for all applicants. Answers to the first four questions are ‘Yes’ with the last question answered ‘No’.

81

Sign and Submit Page

Displayed for all applicants. Answered ‘No’ to the question ‘Did anyone assist you in filling out this application?’.

82

Sign and Submit Page
Displayed for all applicants. Answered ‘Yes’ to the question ‘Did anyone assist you in filling out this
application?’.

83

Sign and Submit Page

Displayed for all applicants. Answered ‘No’ to the question ‘Did anyone assist you in filling out this application?’.
If you are from Benin, Burkina Faso, Cameroon, Central African Republic, Chad, Cote d’Ivoire, Democratic
Republic of the Congo, Djibouti, Egypt, Eritrea, Ethiopia, Gambia, Ghana, Guinea, Guinea-Bissau, Iraq, Kenya,
Liberia, Mali, Mauritania, Niger, Nigeria, Senegal, Sierra Leone, Somalia, Sudan, Tanzania, Togo, Uganda,
Yemen then you will have an extra box on your Sign and Submit page. Applicants must certify they reviewed the
FGM/C government fact sheet, given they are from a FGM/C prevalent country/region.

84

Sign and Submit Page

Displayed for all applicants. Answered ‘Yes’ to the question ‘Did anyone assist you in filling out this application?’.
If you are from Benin, Burkina Faso, Cameroon, Central African Republic, Chad, Cote d’Ivoire, Democratic
Republic of the Congo, Djibouti, Egypt, Eritrea, Ethiopia, Gambia, Ghana, Guinea, Guinea-Bissau, Iraq, Kenya,
Liberia, Mali, Mauritania, Niger, Nigeria, Senegal, Sierra Leone, Somalia, Sudan, Tanzania, Togo, Uganda,
Yemen then you will have an extra box on your Sign and Submit page. Applicants must certify they reviewed the
FGM/C government fact sheet, given they are from a FGM/C prevalent country/region.

85

Confirmation Page

Displayed for applicants when the case is at NVC.

86

Confirmation Page

Displayed for applicants when the case is at Post Displayed for DV applicants when

the case is at KCC

87

Confirmation Page

88

Confirmation Page

Displayed for DV applicants when the case is at Post

89

Copyright Page – Immigrant Visa and Alien
Registration Application

90

Disclaimer Page – Immigrant Visa and Alien
Registration Application

91

Paperwork Reduction Act Page – Immigrant Visa
and Alien Registration Application

92