Name
First Name
Last Name
Merk almal wat geld vir jou
Nuwe Kontak
Nuwe Emails
Nuwe Adres
Getroud (tussen nou en toe jy jou laaste visa gekry het)
Geskei (tussen nou en toe jy jou laaste visa gekry het)
Other
Vul in die Nuwe Info
*
Het jy n nuwe paspoort gekry?
*
Ja
Nee
Nuwe Paspoort Nr.
*
Nuwe Paspoort Begin Datum
*
-
Month
-
Day
Year
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Nuwe Paspoort Verval Datum
*
-
Month
-
Day
Year
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Dorp van uitreiking vir nuwe paspoort
*
Rede vir nuwe paspoort (bv. gesteel/verloor/verval)
*
Foto van Nuwe Paspoort
*
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Datum van aankoms van laaste USA besoek
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-
Month
-
Day
Year
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Datum van vertrek van laaste USA besoek
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-
Month
-
Day
Year
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Duur van verblyf (Bv. 8 Maande)
*
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Het jy al n USA lisensie gehad
Yes
No
USA license No.
*
Staat van USA lisensie (Bv. Louisiana)
*
Konsulaat van laaste Visa
*
Durban
Johannesburg
Kaapstad
Laaste USA Visa Nr. (Rooi Nr. Regs onder op jou visa)
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Datum van uitreiking van laaste USA Visa
*
-
Month
-
Day
Year
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Verval Datum vir laaste USA Visa
*
-
Month
-
Day
Year
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Foto van laaste USA Visa
*
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Huidige werk in Suid Afrika
*
Besigheid
Plaas werk
Retail
Not Employed
Other
Configurable list
*
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Laaste USA werk: Plaas naam
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Laaste USA werk: Baas se Naam en Van
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Laaste USA werk: Adres
*
Begin Datum
*
-
Month
-
Day
Year
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Eindegings Datum
*
-
Month
-
Day
Year
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Nommer
*
Posisie
*
Toesighouer Naam en Van
*
Beskryf wat jy doen
*
Lys al die lande waar jy al was in die laaste 5 jaar
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Security Vrae is in Engels
Have you belonged to, contributed to or worked for any professional, social or charitable orginization?
*
Ja
Nee
Do you have any specialized skills or training, such as firearms, explosives, nuclear, biological or chemical experience?
*
Ja
Nee
Have you ever served in the military?
*
Ja
Nee
Have you ever served in, been a member of, or been involved with paramilitary unit, vigilant unit, rebel group, guerrilla group, or insurgent orginization?
*
Ja
Nee
Do you have a communicable disease of public health significeance? (for example: Gonorrhea, Herpes, Granuloma Inguinale)
*
Ja
Nee
Do you have a mental or physical disorder that poses or is likely ot pose a threat to the saftety or wealthfare of yourself or others?
*
Ja
Nee
Are you or have you ever been a drug abuser or addict?
*
Ja
Nee
Have you ever been arrested or convicted for any offense or crime, even though subject of pardon, amnesty, or other similar action?
*
Ja
Nee
Have you ever violated, or engaged in a conspiracy to violate, any law relating to control substances?
*
Ja
Nee
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?
*
Ja
Nee
Have you ever been envolved in, or do you seek to engage in, money laundering?
*
Ja
Nee
Have you ever commited or conspired to commit a human trafficking offense in the United States or out side of the United States?
*
Ja
Nee
Are you the spouse, son, or daughter of 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 5 years, knowing benefited from the trafficking activities?
*
Ja
Nee
Have knowingly added, abetted, assited or colluded wih an individual who has commited or conspired to commit a severe human trafficking offense in the Unites States or out side of the United States?
*
Ja
Nee
Do you seek to engage in espionage, sabotage, export control violations, or any other illegal activity while in the United States?
*
Ja
Nee
Do you seek to engage in terrostic acitvities while in the United States or have you ever engaged in terrorist activties?
*
Ja
Nee
Have you ever or do you intend to provide financial assitance or other support to terrorists or terrorist organizations?
*
Ja
Nee
Are you a member or representative of a terrorist organization?
*
Ja
Nee
Are you the spouse, son, or daughter of an individual who has engaged in terrorist activity, including providing financial assitance or other support to terrorists or terrorist organizations, in the last five years?
*
Ja
Nee
Have you ever ordered, incited, committed, assisted, or otherwise participated in genocide?
*
Ja
Nee
Have you ever commited, ordered incited, assisted, or otherwise participated in torture?
*
Ja
Nee
Have you committed, ordered, incited, assisted, or otherwise participated in extrajudical killings, political killings, or other acts of violence?
*
Ja
Nee
Have you ever engaged in the recruitment or the use of the child soldiers?
*
Ja
Nee
Have you, while serving as a government official, been responsible for or directly carried out, at any time, particularly servere violations of religious freedom?
*
Ja
Nee
Have you ever been direclty involved inthe establishment or enforcement of the population controls forcing a woman to undergo an abortion against her free choice or a man or a woman to undergo sterlization against his or her free will?
*
Ja
Nee
Have you ever been directly involved in the coercive transplantation of human organs or bodily tissue?
*
Ja
Nee
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?
*
Ja
Nee
Have you ever been removed or deported from any country?
*
Ja
Nee
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?
*
Ja
Nee
Have you voted in the United States in violation of any law or regulation?
*
Ja
Nee
Have you ever renounced United States citizenship for the purpose of avoiding taxation?
*
Ja
Nee
Are you a former exhcange visitor (J) who has not yet fulfilled the two-year foreign residence requirement?
*
Ja
Nee
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