A.

Personal Information 1
Data dan ejaan harus sesuai dengan yang tercantum pada passport
1 Surnames AYUB
2 Given Names MUHAMMAD
3 Full Name in Native Alphabet AYUB MUHAMMAD
4 Have you ever used other NO If Yes :( )
names (i.e. maiden, religious,
professional, etc?
5 Sex MALE
6 Marital Status
MARRIED
7 Date & Place of Birth JAKARTA, APRIL 04 1984

8 State / Province of Birth JAKARTA

9 Country of Birth INDONESIA
B. Personal Information 2
If Not Apply type N/A
1 Nationality INDONESIA
2 Do you hold or have you held a NO If Yes :(..)where
nationality other than the one
you have indicated above?
3 National Identification Number 3172020404840025
(No. KTP)
4 U.S Social Security Number If Apply:
5 U.S Taxpayer ID Number If Apply:
C. Address and Phone
1 Street address (including JL. WARAKAS 9 GANG 13 NO. 84 RT:009 RW:013 KEL. WARAKAS
RT/RW/Nama KEC. TG.PRIUK
Perumahan/Kelurahan/Kecamat
an)
2 City JAKARTA
3 State / Province JAKARTA
4 Postal Zone / Zip Code 14340
5 Country INDONESIA
6 Is your mailing address its YES If No:(.)where
same as your home address?

7 Home Phone Number 021-43913165

8 Work Phone Number
9 Work Fax Number
10 Mobile/Cell Number 0812-90858920
11 E-mail Address YOEBALODI181211@GMAIL.COM
D. Passport Information
1 Passport Number T 123420
2 Passport Book Number If Apply:
3 Country/Authority that Issued TANJUNG PRIUK
Passport
4 Where was the passport issued

- City JAKARTA
- State/Province JAKARTA
- Country INDONESIA
- Issuance date APRIL, 22 2009
- Expiration date APRIL, 22 2014
5 Have you ever lost a passport or NO If Yes :( &) passport number
had one stolen? & country/authority that issued passport

E. Travel Information
1 Are you the principal applicant?

2 Purpose of trip to US
student/exchange visa
F,J,M,Q
Other
Other - Specify
3 Have you made specific travel
plans?
4 Intended date of arrival
5 Intended length of stay in U.S
6 Address where you will stay in U.S
- Street address
- City
- State
- Zip Code (if known)
7 Person/entity, paying for your trip
F. Travel Companions Information
1 Are there other persons travelling with you? NO

G. Previous US Travel Information

1 Have you ever been in U.S? No If Yes complete below (Provide information
on your last 5 U.S. visits)
1.(DECEMBER, 12 2009 COSTA ATLANTICA CRUISE LINE
4 MONTHS)date of arrival &
length of stay
2.(JANUARI, 16 2013 BAHAMAS CELEBRATION CRUISE
LINE5 MONTHS 10
DAYS)date of arrival & length of
stay
3.( )date of arrival & length of
stay
4.( )date of arrival & length of
stay
5.( )date of arrival & length of
stay
2 Do you or did you ever hold a US NO If Yes: ..&.
Drivers License? (Drivers license number & State of
drivers license)
3 Have you ever been issued a U.S No If Yes complete below
Visa? (NOVEMBER, 25 2009)date
last visa was issued
Visa Number : 58135805..
4 Are you applying for the same type NO
of visa?
5 Are you applying in the same NO
country where the visa above was
issued and is this country your
principal country of residence?
6 Have you been ten printed? NO
7 Has your US Visa ever been lost or NO If Yes enter year visa was lost or stolen: .
stolen?
8 Has your US Visa ever been NO If yes explain: ..
cancelled or revoked?
4 Have you ever been refused a U.S NO If yes explain: ..
Visa, been refused admission to the
U.S or withdrawn your application
for admission at the point of entry?
H. US Point of Contact Information
1 Contact Person / Organization in U.S
- Surname
- Given Names
- Organization Name
- Relationship to you
2 Address and phone number of point of contact
a. U.S Street Address
b. City
c. State
d. Zip Code
e. Phone Number
f. E- mail Address
I. Family Information : Relatives
1 Father
- Surname ZAKARIA
- Given Names
- Date of Birth FEBRUARY, 15 1943
- Is your father in U.S? NO

2 Mother
- Surname ARKINAH
- Given Names
- Date of Birth DECEMBER, 16 1944
- Is your mother in U.S? NO

3 Do you have any immediate relatives, NO

not including parents in U.S?
4 Do you have any other relatives in NO
U.S?
 J. Family Information: Spouse (if married)
1 Spouse Full Name (include Maiden Name)
- Surname YULISTINA
- Given Names KHOLODIA
- Date of Birth AUGUST, 17 1986
- Place of Birth SUKANEGARA, LAMPUNG
- Nationality INDONESIA
- Address WARAKAS 9 GANG 13 NO 84 RT: 009 RW: 013 KEL. WARAKAS KEC.
TG.PRIUK
- City JAKARTA
- Country INDONESIA
K. Present Work/Education/Training Information
Silahkan pilih salah satu dari pilihan yang ada di bawah ini. Apabila pekerjaan anda saat ini tidak ada
dalam pilihan seperti tersebut di bawah silahkan pilih OTHER:
NOT EMPLOYED
1 If NOT EMPLOYED Explain: Stay At Home
2 If OTHER Specify: .
a. Present employer or school
name
b. Present employer or school address
- Street address
- City
- State/Province
- Postal Zone/Zip Code
- Country
- Monthly salary in local
currency
- Briefly describe your duty -
-
-
-
3 If BUSINESS/CULINARY OR FOOD SERVICES/AGRICULTURAL/
c. Present employer or school
name
d. Present employer or school
address
- Street address
- City
- State/Province
- Postal Zone/Zip Code
- Country
- Monthly salary in local Rp..
currency
- Briefly describe your duty -
-
-
-
L. Previous Work/Education/Training Information
Tuliskan 5 tahun terakhir pengalaman kerja anda jika memungkinkan
1 Were you previously employed? If Yes fill out form below
2 Employment Information
A - Employer Name MIAMI FLEET QUANTUM JOGJA
- Employer Address
a. Street Address JL. KOLONEL SOEGIONO NO. 65
b. City JOGJAKARTA
c. State/Province MIDLE JAVA
d. Postal Zone/ Zip Code
e. Country INDONESIA
- Phone Number 0817269977
- Job Title SENIOR ATTENDANT
- Supervisors Surname MARIUS
- Supervisors Given Name
- Employment Date From JANUARY, 16 2013
- Employment Date To JUNE, 25 2013
- Briefly describe your duty KEEP CLEANLINESS PAX CABIN ON BOARD

B - Employer Name MERANTI MAGSAYSAY ( COSTA CROCIERE / COSTA PACIFICA )

- Employer Address
f. Street Address JL. TANJUNG KARANG NO. 5
g. City JAKARTA
h. State/Province JAKARTA
i. Postal Zone/ Zip Code 10230
j. Country INDONESIA
- Phone Number 021-3908812, 3908893
- Job Title HOUSEKEEPING STEWARD
- Supervisors Surname JAIRO
- Supervisors Given Name VARGAS
- Employment Date From FEBRUARY, 02 2012
- Employment Date To OCTOBER, 04 2012
- Briefly describe your duty KEEP CLEANLINESS PAX CABIN ON BOARD

C - Employer Name MERANTI MAGSAYSAY ( COSTA CROCIERE / COSTA

MEDITERRANEA )
- Employer Address
k. Street Address JL. TANJUNG KARANG NO. 5
l. City JAKARTA
m. State/Province JAKARTA
n. Postal Zone/ Zip Code 10230
o. Country INDONESIA
- Phone Number 021- 3908812, 3908893
- Job Title HOUSEKEEPING STEWARD
- Supervisors Surname
- Supervisors Given Name
- Employment Date From 25/01.../2011..(dd/mm/yyyy)
- Employment Date To 30/10.../2011..(dd/mm/yyyy)
- Briefly describe your duty - KEEP CLEANLINESS PAX CABIN ON BOARD
-
-
-
D - Employer Name MERANTI MAGSAYSAY ( COSTA CROCIERE / COSTA
ATLANTICA )
- Employer Address
p. Street Address JL. TANJUNG KARANG NO. 5
q. City JAKARTA
r. State/Province JAKARTA
s. Postal Zone/ Zip Code 10230
t. Country INDONESIA
- Phone Number 021- 3908812, 3908893
- Job Title HOUSEKEEPING STEWARD
- Supervisors Surname
- Supervisors Given Name
- Employment Date From 12/12/2009(dd/mm/yyyy)
- Employment Date To 04/09/2010(dd/mm/yyyy)
- Briefly describe your duty - KEEP CLEANLINESS PAX CABIN ON BOARD
-
-
-
E - Employer Name BOROBUDUR HOTEL JAKARTA
- Employer Address
u. Street Address JL. LAPANGAN BANTENG SELATAN
v. City JAKARTA
w. State/Province JAKARTA
x. Postal Zone/ Zip Code 1329
y. Country INDONESIA
- Phone Number 021- 3805555
- Job Title DAILY WORKER WAIT PERSON
- Supervisors Surname ADI
- Supervisors Given Name
- Employment Date From 01/06/2009(dd/mm/yyyy)
- Employment Date To 31/10/2009(dd/mm/yyyy)
- Briefly describe your duty - PREPARATION AND KEEP CLEANLINESS ON BUFFET
STAND
- SERVING FOOD
-
-
3 Have you attended any educational YES If Yes complete below
institutions other than elementary
school?
ELEMENTARY SCHOOL
- Name of institution SD TAMAN HARAPAN
- Street address JL. WARAKAS 6 GANG 2 JAKARTA UTARA
- City JAKARTA
- State/Province JAKARTA
- Zip Code 14340
- Country INDONESIA
- Course of Study GENERAL
- Date of attendant from 1991
- Date of attendant to 1997
JUNIOR HIGH SCHOOL
- Name of institution SMP NEGERI 129
- Street address JL. WARAKAS VI TG. PRIUK
 - City JAKARTA
- State/Province JAKARTA
- Zip Code 14340
- Country INDONESIA
- Course of Study General
- Date of attendant from 1997
- Date of attendant to 2000
SENIOR HIGH SCHOOL
- Name of institution SMU NEGERI 80
- Street address JL. SUNTER KARYA SELATAN V SUNTER PODOMORO
- City JAKARTA
- State/Province JAKARTA
- Zip Code
- Country INDONESIA
- Course of Study GENERAL
- Date of attendant from 2000
- Date of attendant to 2003
COLLEGE OR UNIVERSITY
- Name of institution KRISANTI WIDYA MANDIRI
- Street address JL. KAMPUNG MELAYU KECIL V NO. 22
- City JAKARTA
- State/Province JAKARTA
- Zip Code 12840
- Country INDONESIA
- Course of Study TOURISM / HOTEL
- Date of attendant from 04/07 /2005 (dd/mm/yyyy)
- Date of attendant to 06/07 /2006 (dd/mm/yyyy)
Jika Anda pernah mengikuti kursus suatu bidang yang mendukung pekerjaan anda lengkapi form di bawah
A - Name of institution INTERNATIONAL SYSTEM INSTITUTE OF ENGLISH CBS
- Street address JL. RAYA SUNGAI BAMBU 17 A
- City JAKARTA
- State/Province JAKARTA
- Zip Code
- Country INDONESIA
- Course of Study ENGLISH
- Date of attendant from MARCH, 05 2006
- Date of attendant to MAY, 17 2006
B - Name of institution COSTA CAMPUS/MERANTI MAGSAYSAY
- Street address JL. TANJUNG KARANG NO. 5
- City JAKARTA
- State/Province JAKARTA
- Zip Code 10230
- Country INDONESIA
- Course of Study HOUSEKEEPING
- Date of attendant from 03/03/2009 (dd/mm/yyyy)
- Date of attendant to 03/04/2009 (dd/mm/yyyy)
C - Name of institution
 - Street address
- City
- State/Province
- Zip Code
- Country
- Course of Study
- Date of attendant from / / (dd/mm/yyyy)
- Date of attendant to / / (dd/mm/yyyy)
D - Name of institution
- Street address
- City
- State/Province
- Zip Code
- Country
- Course of Study
- Date of attendant from / / (dd/mm/yyyy)
- Date of attendant to / / (dd/mm/yyyy)
M.Additional Work/Educational/Training Information
1 Do you belong to a clan or tribe? NO If Yes: ..(clan or tribe name)
2 Have you traveled to any countries YES If Yes complete below
within the last 5 years? ( SWEDEN....)country
( FINLANDIA...)country
( GREECE.....)country
( ITALIA....)country
( BRAZIL..)country
( GERMANY..)country
( NORWAY..)country
( TURKEY..)country
3 Have you belonged to, contribute to, NO
or worked for any professional,
social, or charitable organization?
4 Do you have any specialized skills NO
or training, such as firearms,
explosives, nuclear, biological or
chemical experience?
5 Have you served in the military? NO
6 Have you served in, been member NO
of, or involved with paramilitary
unit, vigilante unit, rebel group,
guerilla group, or insurgent
organization?
N. Security and Background: Medical & Health Information
1 Do you have a communicable disease of public health significance such as NO
Tuberculosis?
2 Do you have a mental or physical disorder that poses or liable to pose a threat to NO
the safety or welfare of yourself or other?
3 Are you or have you ever been a drug abuser or addict? NO
O. Security and Background: Criminal Information
1 Have you ever been arrested or convicted for any offense or crime, even though NO
 subject of pardon, amnesty or other similar action?
2 Have you ever violated, or engaged in a conspiracy to violate, any law relating to NO
controlled substances?
3 Are you coming to US to engage in prostitution or unlawful commercialized vice NO
or have you ever involved in prostitution or procuring prostitutes within the past
10 years?
4 Have you ever involved in, or do you seek to engage in, money laundering? NO
P. Security and Background: Security Information
1 Do you seek to engage in espionage, sabotage, export control violations, or any NO
illegal activity while in US?
2 Do you seek to engage in terrorist activities while in US or have you ever engage NO
in terrorist activities?
3 Have ever or do you intend to provide financial assistance or other support to terrorists or NO
terrorist organizations?
4 Are you a member or representative of a terrorist organization? NO

5 Have you ever ordered, incited, committed, assisted, or otherwise participated in NO

genocide?
6 Have you ever committed, ordered, incited, assisted, or otherwise participated in torture? NO
7 Have you committed, ordered, incited, assisted, or otherwise participated in extrajudicial NO
killings, political killings, or other acts of violence?
8 Have you, while serving as government official, been responsible for or directly carried NO
out, at any time, particularly severe violations of religious freedom?
Q. Security and Background: Immigration Law Violation Information
Have you ever sought to obtain or assist other to obtain a visa, entry into the US, or any NO
other US immigration benefit by fraud or willful misrepresentation or other unlawful
means?
R. Security and Background: Miscellaneous Information
1 Have you ever withheld custody of a US citizen child outside the US from a person NO
granted legal custody by a US court?
2 Have you voted in the US in violation of any law or regulation? NO
3 Have you ever renounced US citizenship for the purpose of avoiding taxation? NO
S. Temporary Work Visa Information
1 Where do you intend to work?
- Name of employer
- US Street address
- City
- State
- Zip Code
- Enter monthly salary (in US)
2 Do you have an application
receipt/petition number?
3 Name of person/company who file
Petition
4 Application receipt/Petition Number