U.S. Department of State APPLICATION FOR IMMIGRANT VISA AND ALIEN REGISTRATION OMB APPROVAL NO. 1405-0015 EXPIRES: 07/31/2018 ESTIMATED BURDEN: 1 HOUR* (See Page 2) PART I - BIOGRAPHIC DATA Instructions: Complete one copy of this form for yourself and each member of your family, regardless of age, who will immigrate with you. Please print or type your answers to all questions. Mark questions that are Not Applicable with "N/A". If there is insufficient room on the form, answer on a separate sheet using the same numbers that appear on the form. Attach any additional sheets to this form. Warning: Any false statement or concealment of a material fact may result in your permanent exclusion from the United States. This form (DS-230 Part I) is the first of two parts. This part, together with Form DS-230 Part II, constitutes the complete Application for Immigrant Visa and Alien Registration. 1. Family Name First Name Middle Name 2. Other Names Used or Aliases (If married woman, give maiden name) 3. Full Name in Native Alphabet (If Roman letters not used) 4. Date of Birth (mm-dd-yyyy) 7. Nationality (If dual national, give both.) 5. Age 8. Gender Female Male 6. Place of Birth (City or Town) 9. Marital Status Single (Never Married) (Province) (Country) Married Widowed Divorced times. Separated Including my present marriage, I have been married 10. Permanent address in the United States where you intend to live, if known (street address including ZIP code). Include the name of a person who currently lives there. 11. Address in the United States where you want your Permanent Resident Card (Green Card) mailed, if different from address in item #10 (include the name of a person who currently lives there). Telephone number 12. Present Occupation Telephone number 13. Present Address (Street Address) (City or Town) (Province) (Country) Telephone Number (Home) Telephone Number (Office) E-mail Address 14. Spouse's Maiden or Family Name 15. Date (mm-dd-yyyy) and Place of Birth of Spouse 16. Address of Spouse (If different from your own) First Name Middle Name 17. Spouse's Occupation 18. Date of Marriage (mm-dd-yyyy) 19. Father's Family Name 20. Father's Date of Birth (mm-dd-yyyy) 21. Place of Birth First Name 22. Current Address Middle Name 23. If Deceased, Give Year of Death 24. Mother's Family Name at Birth 25. Mother's Date of Birth (mm-dd-yyyy) 26. Place of Birth First Name 27. Current Address Middle Name 28. If Deceased, Give Year of Death DS-230 Part I 07-2015 This Form May be Obtained Free at Consular Offices of the United States of America Previous Editions Obsolete Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com 29. List Names, Dates and Places of Birth, and Addresses of ALL Children. Name Date (mm-dd-yyyy) Place of Birth Address (If different from your own) 30. List below all places you have lived for at least six months since reaching the age of 16, including places in your country of nationality. Begin with your present residence. City or Town Province Country From/To (mm-yyyy) or "Present" 31a. Person(s) named in 14 and 29 who will accompany you to the United States now. 31b. Person(s) named in 14 and 29 who will follow you to the United States at a later date. 32. List below all employment for the last ten years. Employer Location Job Title From/To (mm-yyyy) or "Present" In what occupation do you intend to work in the United States? 33. List below all educational institutions attended. School and Location From/To (mm-yyyy) Course of Study Degree or Diploma Languages spoken or read Professional associations to which you belong 34. Previous Military Service Branch Rank/Position Yes No Dates of Service (mm-dd-yyyy) Military Speciality/Occupation 35. List dates of all previous visits to or residence in the United States. (If never, write "never") Give type of visa status, if known. Give DHS "A" number if any. From/To (mm-yyyy) Location Type of Visa "A" Number (If known) Signature of Applicant Privacy Act and Paperwork Reduction Act Statements Date (mm-dd-yyyy) The information asked for on this form is requested pursuant to Section 222 of the Immigration and Nationality Act. The U.S. Department of State uses the facts you provide on this form primarily to determine your classification and eligibility for a U.S. immigrant visa. Individuals who fail to submit this form or who do not provide all the requested information may be denied a U.S. immigrant visa. If you are issued an immigrant visa and are subsequently admitted to the United States as an immigrant, the Department of Homeland Security will use the information on this form to issue you a Permanent Resident Card, and, if you so indicate, the Social Security Administration will use the information to issue you a social security number and card. *Public reporting burden for this collection of information is estimated to average 1 hour per response, including time required for searching existing data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final collection. You do not have to supply this information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy of this burden estimate and/or recommendations for reducing it, please send them to: PRA_BurdenComments@state.gov. Please do not send Visa Applications to this address. Send Visa Applications to your nearest U.S Embassy or Consulate for processing. DS-230 Part I American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 4 U.S. Department of State APPLICATION FOR IMMIGRANT VISA AND ALIEN REGISTRATION OMB APPROVAL NO. 1405-0015 EXPIRES: 07/31/2015 ESTIMATED BURDEN: 1 HOUR* PART II - SWORN STATEMENT Instructions: Complete one copy of this form for yourself and each member of your family, regardless of age, who will immigrate with you. Please print or type your answers to all questions. Mark questions that are Not Applicable with "N/A". If there is insufficient room on the form, answer on a separate sheet using the same numbers that appear on the form. Attach any additional sheets to this form. The fee should be paid in United States dollars or local currency equivalent, or by bank draft. Warning: Any false statement or concealment of a material fact may result in your permanent exclusion from the United States. Even if you are issued an immigrant visa and are subsequently admitted to the United States, providing false information on this form could be g