Full Name in Native Language: SURNAME………………………………………………………………………………………

GIVING name……………………………………………………………………….

Other Names Used: …………………………………………………………………………………………………

Sex:……………………………………………………………………………………………………

Marital Status: ……………………………………………………………………………

Date of Birth: ……………………………………………………………………………….

Place of Birth: ………………………………………………………………………………………..

Nationality: …………………………………………………………………………………

Other Nationalities:

National Identification Number: ………….……………………………………………………………………..

U.S. Social Security Number: …………………………………………………………………………………

U.S. Taxpayer ID Number: ……………………………………………………………………………………

Home Address: ………………………………………………………………………………………………………..

City: ……………………………………………………………………………………………..

State/Province: ………………………………………………………………………………….

Postal Zone/ZIP Code: …………………………………………………………………………….

Country: GHANA

Same Mailing Address? …………………………………………………………………………………….

Home Phone Number: ……………………………………………………………………………………..

Work Phone Number: …………………………………………………………………………………….

Work Fax Number: …………………………………………………………………………………………….

Mobile/Cell Phone Number: ………………………………………………………………………………….

Email Address: ………………………………………………………………………………………………………………

Passport Number: ………………………………………………………………………………………………

Passport Book Number: …………………………………………………………………………………………………..

Country/Authority that Issued Passport: ……………………………………………………………………………

City Where Issued: …………………………………………………………………………………………………….

State/Province Where Issued: ………………………………………………………………………………………….

Country Where Issued: ……………………………………………………………………………………………………….

Issuance Date: ………………………………………………………………………………………………………………….

Expiration Date:…………………………………………………………………………………………………………………

Have you ever lost a passport or had one stolen? …………………………………………………

Travel Information

Principal Applicant? ……………………………………………………………………………………………………….

▲ Purpose of Your Trip to U.S.

Purpose (1) : …………………………………………………………………………………………………………

Intended Date of Arrival: ……………………………………………………………………………………………………

Intended Length of Stay in U.S.: …………………………………………………………………………………………………

Address where you will stay in the U.S:……………………………………………………………………………………..

…………………………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………

Person/Entity Paying for Your Trip: …………………………………………………………………………………………

Name of Person Paying for Your Trip: ……………………………………………………………………………………….

Telephone: ……………………………………………………………………………………………………………………………….

Email Address: ……………………………………………………………………………………………………………………………….

Relationship to You: ………………………………………………………………………………………………………………….

Is the address of the party paying for your trip the same as your Home or Mailing Address? YES OR
NO

Paying Address: …………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………….

City: ……………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………….

Postal Zone/ZIP Code: ………………………………………………………………………………………………………………….

Country: ……………………………………………………………………………………………………………………………..

▲ Other Persons Traveling with You: …………………………………………………………………………………

Are you traveling as part of a group or organization? …………………………………………….

Persons Traveling with You:…………………………………………………………………………………………

Name (1) : …………………………………………………………………………………………………..

Relationship to You: …………………………………………………………………………………………

Have been issued a U.S visa before. If yes provide the date of issue

Date…………day………………month……………year……………………………………………….

Have you ever been in the U.S.? If yes provide the date of your Arrivals

Date…………day………………month……………year……………………………………………….

Have you ever been issued a U.S. visa? Date………day…………month……………

year…………………………………………………………..

Length of Stay in U.S- Weeks - Days - months

Have you ever been refused a U.S. Visa, been refused admission to the United States, or withdrawn your
application for admission at the point of entry? …………………………………………………………………………………

Explain:
…………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………..

Have been ten-printed yes or no

Has your U.S.visa ever been lost or stolen?

U.S. Contact Information

Contact Person Name in the U.S.:………………………………………………………………………………………………..

Organization Name in the U.S.: ………………………………………………………………………………………………….

Relationship to You: ………………………………………………………………………………………………………………….

U.S. Contact Address:

…………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………….

Phone Number: …………………………………………………………………………………………………………………………………….

Email Address: ……………………………………………………………………………………………………………………………………….

Family Information

Father's Surnames:

Father's Given Names: …………………………………………………………………………………………………………………..

Father's Date of Birth: …………………………………………………………………………………………………………………..

Is your father in the U.S.?.....................................................................................................................

Mother's Surnames: …………………………………………………………………………………………………………………….

Mother's Given Names: ……………………………………………………………………………………………………………………

Mother's Date of Birth: ………………………………………………………………………………………………………………….

Is your mother in the U.S.?...........................................................................................................

▲ Do you have any immediate relatives, not including parents in

the U.S.? ……………………………………………………………………………………………………………………………………………….

Relative Name (1) : ……………………………………………………………………………………………………………

Relationship to you:…………………………………………………………………………………………………………..

Status: U.S. ………………………………………………………………………………………………………………..

Spouse's Full Name: …………………………………………………………………………………………………………………..

Spouse's Date of Birth: ………………………………………………………………………………………………………….

Spouse's Nationality: ………………………………………………………………………………………………………..

Spouse's City of Birth: ………………………………………………………………………………………………………….

Spouse's Country of Birth: ………………………………………………………………………………………………………..

Spouse’s Address: …………………………………………………………………………………………………………………..

Your Primary Occupation:

Working or Schooling

Employer Name………………………………………………………………………………

Employer street Address………………………………………………………………………………………..

City………………………………………………………………….

Country…………………………………………………………………………………………..

Postal Code………………………………………………………………………

Telephone Number…………………………………………………………………

Job Title…………………………………………………………………….

Start Date…………………………………………………………………..

Briefly describe your duties…………………………………………………………………………………………

Monthly Salary………………………………………………………………………………………………………….

Provide the following information on all educational institutions have attended, not including
elementary schools.

Name of institution……………………………………………………………………………….

Street Address ……………………………………………………………………

City…………………………………………………………….

Postal code………………………………………………………………

Course of study……………………………………………………………..

From Day-………………..Month………………..Year…………………………….

To Day………………..month…………………..Year………………………………………….

Were you previously employed? If yes provide information.

Employer Name………………………………………………………………………………

Employer street Address………………………………………………………………………………………..

City………………………………………………………………….

Country…………………………………………………………………………………………..

Postal Code………………………………………………………………………

Telephone Number…………………………………………………………………

Job Title…………………………………………………………………….

Supervisor’s Name……………………………………………………………..

From Day-………………..Month………………..Year…………………………….

To Day………………..month…………………..Year………………………………………….

Briefly describe your duties………………………………………………………………………….

Have you traveled to any countries within the last five years?

Which countries?