USA Visa Data Collection Form for each Applicants

Type of Application Fresh / Renewal / Reapply Code No

No of Past Rejections (Yes/NO) School Code
Relatives in USA (Yes/NO) Past International Travel (Yes/NO)
Petition Filled (Yes/NO) Deportation/Rejection/Overstay in any country (Yes/NO)
Personal, Address, Phone, and Passport Information
Details Applicant Father Mother Spouse
Surname

Given Name as Per Passport

Have you Ever Changed Yes / No Yes / No Yes / No Yes / No
Name
Do you have a tele code that Yes / No Yes / No Yes / No Yes / No
represents your name?
If Yes Give Details
Surname

Given Name as Per Passport

Date of Birth
(DD/MMM/YYYY)
Place of Birth AS Per passport
City
State
Country
Aadhar Card No
Pan Card No
Gender Male / Female Male Female Male / Female
Marital Status of applicant only Single / Married / Divorced / Widowed / Others
Passport Details
Details Applicant Father Mother Spouse
Passport No
Place of Issue
Date of Issue
Date of Expiry
Contact Details
Mobile No
Home No
Work No /School no
Email ID

Have you Ever Lost Yes / No Yes / No Yes / No Yes / No

Passport (If yes Give
Details)
Have you used additional phone numbers or Email ID’s or if Yes Give Details of all the phone Numbers of Email ID’s
in the last five years? (if yes give Details) USED on an additional Sheet
Have you used additional social media platforms in the
last five years?
Languages Known by applicant
English Hindi Marathi Gujarati

Applicants Home Address

Pin Code

City State Country

Is your Mailing Address same as home address if no Give details Bellow
Applicants Mailing
Address

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Name, Date, Signature of Applicant
 Pin Code

City State Country

Spouse Residential
Address
Pin Code
City State Country

Do you have a social media presence? Social Media Provider/Platform (If Yes Give Details)
Platform Identifier Platform Identifier
ASK.FM PINTEREST
DOUBAN YOUKU
FACEBOOK VKONTAKTE(VK)
FLICKR VINE
GOOGLE+ QZONE (QQ)
INSTAGRAM REDDIT
LINKEDIN SINA WEIBO
MYSPACE TENCENT WEIBO
YOUTUBE TUMBLR
TWITTER TWOO
Do you wish to provide information about your presence on any other websites or applications you have used within the last
five years to create or share content (photos, videos, status updates, etc.)? Yes / No
If Yes give Details.
Have you Ever been to USA in Past? (if Yes Give Details Bellow)
Details 1 2 3 4 5
Date
(DD/MMM/YYYY)
No of Days
Have you Ever been Issued USA Visa? (if Yes Give Details Bellow)
Date Visa No. Type of Visa Issued in
(DD/MMM/YYYY)
Country

Have you Ever been Refused USA Visa? (if Yes Give Details Bellow)
Date Type of Visa Applied in Which Country
(DD/MMM/YYYY)

Has Anyone Filled Immigrant Petition on your Behalf with the United States Citizenship & Immigration Services? (if Yes Give
Details Bellow)
Date
(DD/MMM/YYYY)
Type of Petition
Name & relation Filling petition
Contact no of Person Filing details
Email of Person Filing details

Sponsor Details
Surname
Given Names
Relation Ship with Applicant
Address
ZIP Code
City State Country
Contact No Email ID

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Name, Date, Signature of Applicant
 Relatives in USA
Do you have any immediate relatives in USA ? (Immediate relatives Means Applicant Parents, Siblings, Children & Spouse)
Surname
Given Name
Relation
Legal Status in USA
Legal Status in USA means US Citizen, US Legal Permanent Resident (Green Card Holder) Non-Immigrant Visa
(on Work Permit, Students and others) Don’t Know.
Do you have any other relatives in USA ? (all relatives other than Immediate relatives)
Past International Travel details (List name of all countries travelled in past 5 years)

Primary Occupation
Present Employer or School Name
Present Employer or School Address
Present Employer or School Address
City N Pin Code
State
Country
Describe your Duties in Brief.

Work / School Start Date Monthly

Phone No (DD/MMM/YYYY) Income
Have you attended any educational institutions at a secondary level or above?(If More details kindly give the
same on the Additional Sheet) Give all the education details starting from Grade X
Name of Institution
Address of
Institution
Address of
Institution
City:
State/Province:
Country
Zip Code
Course of Study STD X STD X Graduation in
(X/XII…..)
Date of Attendance
From (DD/MMM/YY)
Date of Attendance
To
Name of Institution
Address of
Institution
Address of
Institution
City:
State/Province:
Country
Zip Code
Course of Study Post-Graduation in
(X/XII…..)
Date of Attendance
From(DD/MMM/YY)
Date of Attendance
To
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Name, Date, Signature of Applicant
 Where you previously employed ?(If More details kindly give the same on the Additional Sheet) (You Should
provide details of your Past 2 employment)
Present Past Employment Past Employment
Employer Name
Address of Employer
Address of Employer
City:
State/Province:
Country
Zip Code
Telephone No
Job Title /Designation
Supervisor's Surname
Supervisor's Given Name
Employment Date From
Employment Date to
Briefly describe your
duties
Monthly Income in Not Needed Not Needed
LOCAL Currency
Annual Income from all Not Needed Not Needed
sources in LOCAL
Currency
SECURITY AND BACKGROUND INFORMATION (PLEASE TICK YES OR NO)
and if Yes Give details of the same on Additional Page
Questions Yes / No
Do you belong to a clan or tribe?
Have you belonged to, contributed to, or worked for any professional social, or charitable organization?
Do you have any specialized skills or training, including firearms explosives, nuclear, biological, or chemical experience?
Have you ever served in the military?
Have you ever served in, been a member of, or been involved with a paramilitary unit, vigilante unit, rebel group, guerrilla group, or
insurgent organization?
Do you have a communicable disease of public health significance? (Communicable diseases of public significance include
chancroid, gonorrhea, granuloma inguinale, infectious leprosy, lymphogranuloma venereum, infectious stage syphilis, active
tuberculosis, and other diseases as determined by the Department of Health and Human Services.)
Do you have a mental or physical disorder that poses or is likely to pose a threat to the safety or welfare of yourself or others?
Are you or have you ever been a drug abuser or addict?
Have you ever been arrested or convicted for any offense or crime, even though subject of a pardon, amnesty, or other similar action?
Have you ever violated, or engaged in a conspiracy to violate, any law relating to controlled substances?
Are you the spouse, son, or daughter of an 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 five years, knowingly benefited from the trafficking activities
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 with in past 10 years?
Have you ever been involved in, or do you seek to engage in, money laundering?
Have you ever committed or conspired to commit a human trafficking offense in the United States or outside the United States?
Are you the spouse, son, or daughter of an 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 five years, knowingly benefited from the trafficking activities?
Have you knowingly aided, abetted, assisted or colluded with an individual who has committed or conspired to commit a severe
human trafficking offense in the United States or outside the United States?
Do you seek to engage in espionage, sabotage, export control violations, or any other illegal activity while in the United States?
Do you seek to engage in terrorist activities while in the United States or have you ever engaged in terrorist activities?
Have you ever or do you intend to provide financial assistance or other support to terrorists or terrorist organizations?
Are you a member or representative of a terrorist organization?
Have you ever ordered, incited, committed, assisted, or otherwise participated in genocide?
Have you ever committed, ordered, incited, assisted, or otherwise participated in torture?
Have you committed, ordered, incited, assisted, or otherwise participated in extrajudicial killings, political killings, or other acts of
violence?
Have you ever engaged in the recruitment or the use of the child soldiers?
Have you, while serving as a government official, been responsible for or directly Carried out, at any time, particularly severe
violations of religious freedom?
Have you ever been directly involved in the 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 sterilization against his or her free will?
Have you ever been directly involved in the coercive transplantation of human organs or Bodily tissue?
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?
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?
Have you voted in the United States in violation of any law or regulation?

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Name, Date, Signature of Applicant
 Are you the spouse, son, or daughter of an individual who has engaged in terrorist activity, including providing financial assistance or other
support to terrorists or terrorist organizations, in the last five years?
Have you ever been removed or deported from any country?
Have you ever renounced United States citizenship for the purpose of avoiding Taxation?
If you Travelled to Any Countries with Pandemic of Covid -19 post 15 Jan 2020 (If yes) (You may be asked by Consulate to undergo
Medical Examination as per Consulate(s) Norms) (it is just for your Information)
Important Notes about Your Visa Applications
All Visa Forms filled are based on the data given and confirmed by Applicant. Applicant is solely responsible for its accuracy. Applicant should understand that any false data/ information given/
material information is suppressed, with a view to obtain visa is a criminal offence and Applicant is solely responsible for its consequences.
Applicant must sign the visa form only when it is fully filled and after verifying its data/ information. Once the form is signed the applicant is
Solely responsible for its accuracy.
In case Consulate requires additional Documents / Details, they may ask for it, and the applicant needs to provide the same based on which the visa may be issued / rejected.
Visa processing time may change from period to period depending on load factor with the consulate. Bio Metrics & Consular Appointment is allocated as per the availability in their system at the
time of application.
In case of Emergency Dates Earlier dates for Bio Metrics and Consular appointment, we can send the request to Consulate and they can approve if the documents sent to them justifies your
reason of Emergency Date Request. (Medical Needs / Funeral/Death / Urgent Business Travel / Students or exchange visitors / ESTA Denied.)
Our Service Charges are for filling forms, submitting the Application online to consulate, advising for the documents in order to be carried at the time of Interview and Guiding you through the
process.
• Your application once ready to be submitted online. Please note that this does not necessarily mean that your application for a non-immigrant visa is complete, as
additional information may be needed after Department of State personnel have reviewed the application.
• By clicking “Sign and Submit Application” you are electronically signing the application.
• You are required to electronically sign your application yourself, unless otherwise exempt by regulation, even if the application has been prepared by someone other
than yourself.
• Your electronic signature certifies that you have read and understood the questions in this application and that your answers are true and correct to the best of your
knowledge and belief.
• The submission of an application containing any false or misleading statements may result in the permanent refusal of a visa or the denial of entry into the United
States.
• All declarations made in this application are unsworn declarations made under penalty of perjury. (28 U.S.C. 1746).
• The information that you have provided in your application and other information submitted with your application may be accessible to other government
agencies having statutory or other lawful authority to use such information, including for law enforcement and immigration law enforcement purposes.
• The photograph that you provide with your application may be used for employment verification or other U.S. law purposes.
• I Know that Approval of refusal of Visa is in the Sole Power of the Consular officer and Dipesh Tours or its team cannot be held responsible in manner for
the same. All the losses due to refusal of the visa will be to my account and will not claim any of them form Dipesh Tours or their team. Dipesh Tours or
their team do not have any say or do not influence Approval or Refusal of visa.
• I have filled all the pages of the details form of M/s Dipesh Tours and I am solely responsible for the accuracy of the same.
• I hereby authorize M/s Dipesh Tours process the visa application on my behalf and to Complete the Process by Clicking “Sign and Submit Application”.
• I will be solely responsible for any wrong information or mistake in the form. I will sign the form online only after verifying the same.
• You electronically signed your application on _______________ (GMT-05:00). You were required to electronically sign your application yourself, unless
otherwise exempt by regulation, even if the application was prepared by someone other than yourself. Your electronic signature certifies that you have
read and understood the questions in this application and that your answers are true and correct to the best of your knowledge and belief. The submission
of an application containing any false or misleading statements may result in the permanent refusal of a visa or the denial of entry into the United States.
All declarations made in this application are unsworn declarations made under penalty of perjury. (28 U.S.C. 1746).
• You certified that you understand that you are required to submit your visa to the United States Immigration Officer at the port where you apply to enter
the United States, and that possession of the visa does not entitle you to enter the United States if, upon your arrival, you are found to be inadmissible
under U.S. immigration laws. You certified that you understand that any wilfully false or misleading statement or wilful concealment of a material fact made
by you within the application may subject you to permanent exclusion from the United States and, if you are admitted to the United States, may subject
you to criminal prosecution and/or deportation.
• The information that you have provided in your application and other information submitted with your application may be accessible to other government
agencies having statutory or other lawful authority to use such information, including for law enforcement and immigration law enforcement purposes. If
fingerprints are collected as part of your application process, they may be used for the purpose of comparing them to other fingerprints in the FBI’s Next
Generation Identification (NGI) fingerprint system or its successor systems (including civil, criminal, and latent fingerprint repositories). The photograph
that you provide with your application may be used for employment verification or other U.S. law purposes
• We here by Affirm and Confirm that we are aware about the Approval or Denial of Visa and the Time frame for the Processing of the application, Approving
the Bio Metrics & Consular Appointment date is at the sole discretion of the Consulate and their availability slots, We will not, cannot hold Dipesh Tours,
Travel/Tour Operator, School Authorities responsible for Approval or Denial of Visa and the Time frame for the Processing of the application, Approving
the Bio Metrics & Consular Appointment date. We will adhere to the dates given to us on approval from the Consulate
• We are aware the Issuance of Visa is at sole decision of Consular taking interview at the Counter at consulate. Visa could be issued to our Child only if that
are able to articulate their non-Immigrant Intention to Visa officer during the Visa Interview. We will not, cannot hold Dipesh Tours, Travel/Tour Operator,
School Authorities responsible for Approval or Denial of Visa and the Time frame for the Processing of the application post approval of Visa
• We are aware that there are time to time Change on the Visa application process & issuance, Immigrations laws at the port of Boarding and embarking,
Also if the visa is issued at the time of interview and then later afterwards the Consulate may call back and revoke their decision of issuance, Permission
of Entry in to the Country at the port of entry is in the sole discretion of the immigration authorities at the port of entry, and we will abide with the same
and We will not, cannot hold Dipesh Tours, Travel/Tour Operator, School Authorities responsible for the same.

Applicants Name
Applicants Signature

Date
Location
If Form Filled by Some else other, then applicant
Name
Signature

Date
Location

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Name, Date, Signature of Applicant
 Suggested Document Check List for Tourist USA Visa

To be submitted for to us so that we can start the Visa application process

1. Data Collection form for Visa In original

2. Applicants Passport (Recent Valid Passport with minimum validity of 180 days from Xerox Copies of all 36 pages
date of return and atleast 3 blank pages)
3. Father Passport Xerox copy of 1st and last page only
4. Mother Passport Xerox copy of 1st and last page only

Documents to Be carried in Harmonium folder During Mock Interview and Interview

1. Applicants Passport (recent Valid Passport with minimum validity of 180 days from date of return and atleast 3 In original
blank pages along with all old Passport )
2. Father’s Passport (in case of applicant is minor) In original
3. Mother’s Passport (in case of applicant is minor) In original
4. Student’s School/ College I Card / Office I Card In original
5. Bonafide Certificate form School/ College / Leave Letter & NOC from Company In original
6. Family Photo (Post Card Size is ok, with all the family members staying at same address) In original
7. Applicant / Father’s, Mother’s, Child’s, HUF’s (if any) Bank Statement for last 6 months with bank seal. In original
8. Applicant /Father’s, Mother’s, Sponsor’s Income Tax Papers for Last 3 years along with Detailed Balance sheet In original
9. Covering Letter on the letterhead of Applicants or Parents in case of Minor In original
10 Sponsorship Affidavit from Parents & Sponsor on ₹ 100 Stamper and Notarized (In case of Minor) In original
11. Proof of Business For Applicants / if parents are Sponsoring & parent owning In original
Business - Proprietor Company
Licenses of that business Such as Shop n Establishment, GST and others as applicable to business.
Business – Partnership firm
Licenses of that business Such as Partnership deed, Shop n Establishment, GST and others as applicable to
business.
Business – Private Limited / Public Limited
Licenses of that business Such as articles of association (AoA) , Memorandum of Association (MoA),
Certificate of Incorporation (CoI), Shop n Establishment, GST and others as applicable to business.
12. Proof of Income Applicants / Parents if applicant is minor In original
• Appointment letter
• Salary Slips,
• Rental Agreements
• Fixed Deposit Interest
• Commission Income and so on as applicable to Individual.
13. Proof of Investments Applicants / Parents if applicant is minor In original
Movable assets :. Bank Statement for last 6 months, PPF, P.F., Demat Account
Statement and others.
Immovable assets :. Agreement Copy of home, shop, office, plot and others).
14. Proof of Relatives in USA (if any, then applicant should know the details of the relative in USA). Xerox
15. Proof of Parents or other family members or friend holding visa. In original

Please Note:

1. Above are the Documents suggested from our Experience. Consular officer can or may ask any document to prove as
supporting to our Verbal Communication and hence be prepared and keep those documents along with you at the time of
Interview. Do not give any documents unless and until Asked / Demanded by Visa officer.
2. We request you to kindly keep all the documents handy at the time of Interview in presentable format, Officer may or may not
ask for any documents to be seen, and in case asks and applicant cannot provide documentary evidence that the Visa officer
may inform applicant to try again. (that means it is rejected under 214(b)) .
3. Be aware that the issuance of visa is at sole discretion of Consular officer taking interview across the Counter at consulate. Visa
could be issued to any or all applicants only if they are able to articulate their non-Immigrant Intention to Visa officer during the
Visa Interview. (Depending on the Category of Visa applied)
4. Dipesh Tours, Travel/Tour Operator, School Authorities, Any Agent do not have any say in decision of approval or Denial of visa
and it is at sole discretion of Consular Visa officer taking Interview and the Facts given to them in the Visa application form filled
online.
5. Consular General and their team have their own process of deriving / verifying the facts submitted to them online in visa
application form.

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Name, Date, Signature of Applicant