• Name*
  First NameMiddle NameLast Name
• Name of the farm you will be working on.*
• Please select the consular office you would like to use.*
  JohannesburgCape TownDurban
• This will be my 1st year as an H2A worker.*
  YesNo
• Where would you like DHL to deliver your passport after the consular office has finished with it.*
  Street Address

  Street Address Line 2

  CityState / Province

  Postal / Zip Code
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• PERSONAL INFORMATION

• Full name in mother language? (N/A if not applicable)*
• Have you used any other names?*
  YesNo
• Please select one?*
  MaleFemale
• Marital Status.*
  MarriedSingleDivorcedOther
• Spouse Information*
• Former Spouse*
• Home Adress*
  Street Address

  Street Address Line 2

  CityState / Province

  Postal / Zip Code
• Is your mailing address the same as your home address?*
  YesNo
• Mailing Address*
  Street Address

  Street Address Line 2

  CityState / Province

  Postal / Zip Code
• Date of birth*
   -Day -MonthYear

  Date
• Place of Birth.*
  Street Address

  Street Address Line 2

  CityState / Province

  Postal / Zip Code
• South African ID number*
• Social Security Nr*
  If you do not have one input 11
• U.S. Tax ID nr.
• Primary Phone nr.*
  Please enter a valid phone number.
• Secondary Phone nr.
  Please enter a valid phone number.
• Work Phone nr.
  Please enter a valid phone number.
• Have you used any other phone numbers in the last 5 years?*
  YesNo
• Other number used within the last 5 years*
• Email*
  example@example.com
• Have you used any other emails in the last 5 years?*
  YesNo
• Other email used in last 5 years.*
  example@example.com
• Please enter one of your social media platforms (i.e. Facebook - John Brown)*
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• Country or Region of origin.*
• Have you ever held a nationality other that the one named above?*
  YesNo
• Are you a permanent resident of a country/region other than the Nationality listed above?*
  YesNo
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• PASSPORT

• Passport Nr.*
• Passport Book nr (Does not apply to SA passports)
• Where was your passport issued?*
  Street Address

  Street Address Line 2

  CityState / Province

  Postal / Zip Code Please Select Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Curaçao Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Nagorno-Karabakh Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Turkish Republic of Northern Cyprus Northern Mariana Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Republic of the Congo Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia South Sudan Spain Sri Lanka Sudan Suriname Svalbard eSwatini Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Transnistria Pridnestrovie Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands Isle of Man US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country
• Passport Issued date*
   -Month -DayYear

  Date
• Passport Expiery date*
   -Month -DayYear

  Date
• Have you ever lost a passport or had one stolen?*
  YesNo
• Please Explain*
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• U.S INFORMATION

• Who will be paying for your trip?*
  Employer in the U.SSelf
• Have you ever been ten printed? (This is if they have taken electronic finger prints of all of your fingers at a U.S. consulate?)*
  YesNo
• Have you ever been refused a U.S visa (This is if your visa was completely denied)*
  YesNo
• Have you ever been to the United States?*
  YesNo
• Date of Last U.S visit*
• Date of previous U.S visit
• Date of previous U.S visit
• Date of previous U.S visit
• Date of previous U.S visit
• Date last U.S visa was Issued*
   -Month -DayYear

  Date
• Last U.S visa number. (it is the red number on the bottom right of the visa)*
• Have you every had a U.S License*
  YesNo
• State License was issued*
  Street Address

  Street Address Line 2

  City Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia 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 Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State

  Zip Code
• Last U.S License number*
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• Father *
• Mother*
• Do you have any direct family in the U.S?*
  YesNo
• Information for direct family member in U.S*
• Do you have any other family in the U.S?*
  YesNo
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• PRESENT EMPLOYMENT

• Present Employer in South Africa*
  AgricultureBusinessHomemakerRetailNot EmployedOther
• Please Explain*
• Present Employer*
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• PREVIOUS EMPLOYMENT

• Were you previously employed? (YOU MUST ENTER YOUR LAST USA JOB IF YOU HAD ONE)*
  YesNo
• Previous Employer*
• Have you attended an educational institution at a secondary level or above?*
  YesNo
• School Info*
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• Do you belong to a clan or tribe?*
  YesNo
• List all Languages you speak.*
• List all Countries/Regions visited in the last five years.*
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• ADDITIONAL QUESTIONS

• Have you belonged to, contributed to or worked for any professional, social or charitable orginization?*
  YesNo
• Do you have any specialized skills or training, such as firearms, explosives, nuclear, biological or chemical experience?*
  YesNo
• Have you ever served in the military?*
  YesNo
• Military Info*
• Have you ever served in, been a member of, or been involved with paramilitary unit, vigilant unit, rebel group, guerrilla group, or insurgent orginization?*
  YesNo
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• SECURITY QUESTIONS

• Do you have a communicable disease of public health significeance? (for example: Gonorrhea, Herpes, Granuloma Inguinale)*
  YesNo
• 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?*
  YesNo
• Are you or have you ever been a drug abuser or addict?*
  YesNo
• Have you ever been arrested or convicted for any offense or crime, even though subject of pardon, amnesty, or other similar action?*
  YesNo
• Have you ever violated, or engaged in a conspiracy to violate, any law relating to control substances?*
  YesNo
• 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?*
  YesNo
• Have you ever been envolved in, or do you seek to engage in, money laundering?*
  YesNo
• Have you ever commited or conspired to commit a human trafficking offense in the United States or out side of the United States?*
  YesNo
• 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?*
  YesNo
• 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?*
  YesNo
• Do you seek to engage in espionage, sabotage, export control violations, or any other illegal activity while in the United States?*
  YesNo
• Do you seek to engage in terrostic acitvities while in the United States or have you ever engaged in terrorist activties?*
  YesNo
• Have you ever or do you intend to provide financial assitance or other support to terrorists or terrorist organizations?*
  YesNo
• Are you a member or representative of a terrorist organization?*
  YesNo
• 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?*
  YesNo
• Have you ever ordered, incited, committed, assisted, or otherwise participated in genocide?*
  YesNo
• Have you ever commited, ordered incited, assisted, or otherwise participated in torture?*
  YesNo
• Have you committed, ordered, incited, assisted, or otherwise participated in extrajudical killings, political killings, or other acts of violence?*
  YesNo
• Have you ever engaged in the recruitment or the use of the child soldiers?*
  YesNo
• Have you, while serving as a government official, been responsible for or directly carried out, at any time, particularly servere violations of religious freedom?*
  YesNo
• 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?*
  YesNo
• Have you ever been directly involved in the coercive transplantation of human organs or bodily tissue?*
  YesNo
• 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?*
  YesNo
• Have you ever been removed or deported from any country?*
  YesNo
• 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?*
  YesNo
• Have you voted in the United States in violation of any law or regulation?*
  YesNo
• Have you ever renounced United States citizenship for the purpose of avoiding taxation?*
  YesNo
• Are you a former exhcange visitor (J) who has not yet fulfilled the two-year foreign residence requirement?*
  YesNo
• Back

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• Please upload a photo of your last U.S visa*
  Browse Files

  Drag and drop files here

  Choose a file

  Cancelof
• Please upload a photo of your Passport*
  Browse Files

  Drag and drop files here

  Choose a file

  Cancelof
• I agree that my agent does not take any responsibility for information that I have input in correctly*
  YesNo
• Submit
• Should be Empty: