U.S. Department of State CLASS A NON-IMMIGRANT VISA REFERRAL TO: Chief of Consular Section SUBJECT: Visa Referral Name of Applicant (Last, First, MI) Date (mm-dd-yyyy) Date (mm-dd-yyyy) and Place of Birth Accompanying(s) - Additional relatives should be listed on back of form. Full Name Relationship Date (mm-dd-yyyy) and Place of Birth I recommend visa issuance for the visa applicant named above who is well and favorably known to me. The following documents are attached: Passport Completed Form DS-156 Completed Form DS-157 and/or DS-158 (If applicable) Photo Supporting Documents MRV Fee Receipt Position of Applicant/Nature of Contact Purpose of Applicant's Travel Date of Travel (mm-dd-yyyy) Destination of Applicant's Travel Issuing a Visa to the applicant is in the U.S. national interest because: (Continue on back if necessary) I certify that to the best of my knowledge, the referred applicant meets all criteria for A referral status and presents no threat to the national security or safety of the United States. Name of Referring Officer Title Signature Date (mm-dd-yyyy) I certify that to the best of my knowledge, the referred applicant meets all criteria for A referral status and presents no threat to the national security or safety of the United States. Name of Approving Officer Title Signature Date (mm-dd-yyyy) Name of Chief of Mission, Deputy Chief of Mission, or Principal Officer Signature Title Date (mm-dd-yyyy) DS-4034 04-2008 American LegalNet, Inc. www.FormsWorkflow.com