Escolar Documentos
Profissional Documentos
Cultura Documentos
ConsularElectronicApplicationCenterPrintApplication
OnlineNonimmigrantVisaApplication(DS160)
ApplicationSensitiveButUnclassified(SBU)
Wedonotneedaprintedcopyofyourapplicationatanypointduringyourinterviewprocess.Onlyprintthis
applicationifyouwantacopyforyourownrecords.Ifyouprintyourapplication,pleasekeepitsecure.
PhotoProvided:
ConfirmationNumber:
YourPersonalCopyDoNotBringtoInterview
Personal,Address,Phone,andPassport/TravelDocumentInformation
NameProvided:
CASTILLOCOLIN,BERNARDITA
FullNameinNativeLanguage:
DOESNOTAPPLY
OtherNamesUsed:
NO
TelecodeNameUsed:
NO
Sex:
FEMALE
MaritalStatus:
WIDOWED
DateofBirth:
16APRIL1958
PlaceofBirth:
AMANALCO,MEXICO,MEXICOSTATEOFMEXICO
Country/RegionofOrigin(Nationality):
MEXICO
Doyouholdorhaveyouheldanynationalityotherthantheone
indicatedaboveonnationality?
NO
Areyouapermanentresidentofacountry/regionotherthanyour
country/regionoforigin(nationality)above?
NO
NationalIdentificationNumber:
0157017371928
U.S.SocialSecurityNumber:
113987601
U.S.TaxpayerIDNumber:
DOESNOTAPPLY
HomeAddress:
ELPOTREROSINNUMERO
City:
AMANALCO
State/Province:
MEXICO
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PostalZone/ZIPCode:
51260
Country/Region:
MEXICO
SameMailingAddress?
YES
PrimaryPhoneNumber:
5544633250
SecondaryPhoneNumber:
7224757157
WorkPhoneNumber:
DOESNOTAPPLY
EmailAddress:
epalomino93@gmail.com
Passport/TravelDocumentType:
REGULAR
Passport/TravelDocumentNumber:
G20621972
PassportBookNumber:
G20621972
Country/AuthoritythatIssuedPassport/TravelDocument:
MEXICO
CityWhereIssued:
TOLUCA
State/ProvinceWhereIssued:
MEXICO
Country/RegionWhereIssued:
MEXICO
IssuanceDate:
12MAY2016
ExpirationDate:
12MAY2022
Haveyoueverlostapassportorhadonestolen?
NO
TravelInformation
TheListofPurposesofTriptotheU.S.
PurposeofTriptotheU.S.(1):
TEMP.BUSINESSPLEASUREVISITOR(B)
Specify:
BUSINESS&TOURISM(TEMPORARYVISITOR)
(B1/B2)
IntendedDateofArrival:
05AUGUST2016
IntendedLengthofStayinU.S.:
2WEEK(S)
AddresswhereyouwillstayintheU.S.:
50LOGDALEST
City,State,Postal/ZipCode:
STATENISLAND,NEWYORK10314
Person/EntityPayingforYourTrip:
OTHERPERSON
PersonPayingforYourTrip:
REYES,ADRIANA
TelephoneNumber:
3472154148
EmailAddress:
DOESNOTAPPLY
RelationshiptoYou:
OTHERRELATIVE
Istheaddressofthepartypayingforyourtripthesameasyour
HomeorMailingAddress?
YES
Arethereotherpersonstravelingwithyou?
YES
Areyoutravelingaspartofagroupororganization?
NO
PersonsTravelingwithYou:
Name(1):
QUINTEROALVAREZ,PETRA
RelationshiptoYou:
OTHERRELATIVE
HaveyoueverbeenintheU.S.?
NO
HaveyoueverbeenissuedaU.S.visa?
NO
HaveyoueverbeenrefusedaU.S.Visa,orbeenrefusedadmission
totheUnitedStates,orwithdrawnyourapplicationforadmissionat
theportofentry?
NO
Hasanyoneeverfiledanimmigrantpetitiononyourbehalfwiththe
UnitedStatesCitizenshipandImmigrationServices?
NO
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U.S.ContactInformation
ContactPersonNameintheU.S.:
REYES,ADRIANA
OrganizationNameintheU.S.:
DONOTKNOW
RelationshiptoYou:
OTHER
U.S.ContactAddress:
50LOGDALEST
STATENISLAND,NEWYORK10314
PhoneNumber:
3472154148
EmailAddress:
DOESNOTAPPLY
FamilyInformation
Father'sSurnames:
CASTILLOLEON
Father'sGivenNames:
AGUSTIN
Father'sDateofBirth:
28AUGUST1933
IsyourfatherintheU.S.?
NO
Mother'sSurnames:
COLINVILCHIS
Mother'sGivenNames:
ANGELINA
Mother'sDateofBirth:
10AUGUST1933
IsyourmotherintheU.S.?
NO
Doyouhaveanyimmediaterelatives,notincludingparentsinthe
U.S.?
NO
DoyouhaveanyotherrelativesintheUnitedStates?
NO
DeceasedSpouse'sFullName:
AVILAVELAZQUEZ,NAVOR
DeceasedSpouse'sDateofBirth:
12JUNE1949
DeceasedSpouse'sCountry/RegionofOrigin(Nationality):
MEXICO
DeceasedSpouse'sCityofBirth:
POTRERO
Country/RegionofBirth:
MEXICOSTATEOFMEXICO
Work/Education/TrainingInformation
PrimaryOccupation:
AGRICULTURE
PresentEmployerorSchoolName:
BERNARDITACASILLOCOLIN
Address:
ELPOTREROSINNUMERO
City:
AMANALCO
State/Province:
MEXICO
PostalZone/ZipCode:
51260
Country/Region:
MEXICO
WorkPhoneNumber:
7224757157
MonthlySalaryinLocalCurrency(ifemployed):
28000
BrieflyDescribeyourDuties:
SIEMBRADEMAIZYGANADOVACUNO
SecurityandBackgroundInformation
Doyouhaveacommunicablediseaseofpublichealthsignificance?(Communicablediseasesofpublic
significanceincludechancroid,gonorrhea,granulomainguinale,infectiousleprosy,lymphogranuloma
venereum,infectiousstagesyphilis,activetuberculosis,andothersdiseasesasdeterminedbytheDepartment
ofHealthandHumanServices.)
NO
Doyouhaveamentalorphysicaldisorderthatposesorislikelytoposeathreattothesafetyorwelfareof
yourselforothers?
NO
Areyouorhaveyoueverbeenadrugabuseroraddict?
NO
Haveyoueverbeenarrestedorconvictedforanyoffenseorcrime,eventhoughsubjectofapardon,amnesty,
orothersimilaraction?
NO
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Haveyoueverviolated,orengagedinaconspiracytoviolate,anylawrelatingtocontrolledsubstances?
NO
AreyoucomingtotheUnitedStatestoengageinprostitutionorunlawfulcommercializedviceorhaveyou
beenengagedinprostitutionorprocuringprostituteswithinthepast10years?
NO
Haveyoueverbeeninvolvedin,ordoyouseektoengagein,moneylaundering?
NO
HaveyouevercommittedorconspiredtocommitahumantraffickingoffenseintheUnitedStatesoroutside
theUnitedStates?
NO
Areyouthespouse,son,ordaughterofanindividualwhohascommittedorconspiredtocommitahuman
traffickingoffenseintheUnitedStatesoroutsidetheUnitedStatesandhaveyouwithinthelastfiveyears,
knowinglybenefitedfromthetraffickingactivities?
NO
Haveyouknowinglyaided,abetted,assistedorcolludedwithanindividualwhohascommittedorconspiredto
commitaseverehumantraffickingoffenseintheUnitedStatesoroutsidetheUnitedStates?
NO
Doyouseektoengageinespionage,sabotage,exportcontrolviolations,oranyotherillegalactivitywhilein
theUnitedStates?
NO
DoyouseektoengageinterroristactivitieswhileintheUnitedStatesorhaveyoueverengagedinterrorist
activities?
NO
Haveyoueverordoyouintendtoprovidefinancialassistanceorothersupporttoterroristsorterrorist
organizations?
NO
Areyouamemberorrepresentativeofaterroristorganization?
NO
Haveyoueverordered,incited,committed,assisted,orotherwiseparticipatedingenocide?
NO
Haveyouevercommitted,ordered,incited,assisted,orotherwiseparticipatedintorture?
NO
Haveyoucommitted,ordered,incited,assisted,orotherwiseparticipatedinextrajudicialkillings,political
killings,orotheractsofviolence?
NO
Haveyoueverengagedintherecruitmentortheuseofthechildsoldiers?
NO
Haveyou,whileservingasagovernmentofficial,beenresponsibleforordirectlycarriedout,atanytime,
particularlysevereviolationsofreligiousfreedom?
NO
Haveyoueverbeendirectlyinvolvedintheestablishmentorenforcementofthepopulationcontrolsforcinga
womantoundergoanabortionagainstherfreechoiceoramanorawomantoundergosterilizationagainsthis
orherfreewill?
NO
Haveyoueverbeendirectlyinvolvedinthecoercivetransplantationofhumanorgansorbodilytissue?
NO
Haveyoueversoughttoobtainorassistotherstoobtainavisa,entryintotheUnitedStates,oranyother
UnitedStatesimmigrationbenefitbyfraudorwillfulmisrepresentationorotherunlawfulmeans?
NO
HaveyoueverwithheldcustodyofaU.S.citizenchildoutsidetheUnitedStatesfromapersongrantedlegal
custodybyaU.S.court?
NO
HaveyouvotedintheUnitedStatesinviolationofanylaworregulation?
NO
HaveyoueverrenouncedUnitedStatescitizenshipforthepurposeofavoidingtaxation?
NO
LocationInformation
Locationwhereyouwillbesubmittingyourapplication
CurrentLocation:
MEXICOCITY,MEXICO
PreparerofApplication
Didanyoneassistyouinfillingoutthisapplication?
YES
PreparerSurnames:
PALOMINOCAMACHO
PreparerGivenNames:
EMMANUEL
OrganizationName:
DOESNOTAPPLY
StreetAddress:
CALTLYLT7MZ365
PLATEROS
City:
CHIMALHUACAN
State/Province:
ESTADODEMEXICO
PostalZone/ZIPCode:
56356
Country/Region:
MEXICO
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RelationshiptoYou:
FRIEND
YourPersonalCopyDoNotBringtoInterview
Youelectronicallysignedyourapplicationon16May201601:18:48(GMT05:00).Youwererequiredtoelectronicallysignyour
applicationyourself,unlessotherwiseexemptbyregulation,eveniftheapplicationwaspreparedbysomeoneotherthan
yourself.Yourelectronicsignaturecertifiesthatyouhavereadandunderstoodthequestionsinthisapplicationandthatyour
answersaretrueandcorrecttothebestofyourknowledgeandbelief.Thesubmissionofanapplicationcontaininganyfalseor
misleadingstatementsmayresultinthepermanentrefusalofavisaorthedenialofentryintotheUnitedStates.Alldeclarations
madeinthisapplicationareunsworndeclarationsmadeunderpenaltyofperjury.(28U.S.C.1746).
YoucertifiedthatyouunderstandthatyouarerequiredtosubmityourvisatotheUnitedStatesImmigrationOfficerattheport
whereyouapplytoentertheUnitedStates,andthatpossessionofthevisadoesnotentitleyoutoentertheUnitedStatesif,
uponyourarrival,youarefoundtobeinadmissibleunderU.S.immigrationlaws.Youcertifiedthatyouunderstandthatany
willfullyfalseormisleadingstatementorwillfulconcealmentofamaterialfactmadebyyouwithintheapplicationmaysubject
youtopermanentexclusionfromtheUnitedStatesand,ifyouareadmittedtotheUnitedStates,maysubjectyoutocriminal
prosecutionand/ordeportation.
Theinformationthatyouhaveprovidedinyourapplicationandotherinformationsubmittedwithyourapplicationmaybe
accessibletoothergovernmentagencieshavingstatutoryorotherlawfulauthoritytousesuchinformation,includingforlaw
enforcementandimmigrationlawenforcementpurposes.Iffingerprintsarecollectedaspartofyourapplicationprocess,they
maybeusedforthepurposeofcomparingthemtootherfingerprintsintheFBIsNextGenerationIdentification(NGI)fingerprint
systemoritssuccessorsystems(includingcivil,criminal,andlatentfingerprintrepositories).Thephotographthatyouprovide
withyourapplicationmaybeusedforemploymentverificationorotherU.S.lawpurposes.
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