Online Immigrant Visa and Alien Registration Application (ds-260)
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| Online Immigrant Visa and Alien Registration Application (DS-260) Personal, Address, and Phone Information Name Provided: _______________________ Full Name in Native Language: _______________________ Other Names Used: _______________________ Sex: _______________________ Current Marital Status: _______________________ Date of Birth: _______________________ City of Birth: _______________________ State/Province of Birth: _______________________ Country/Region of Birth: _______________________ Country/Region of Origin (Nationality): _______________________
Document Type: _______________________ Document ID: _______________________ Country/Authority that Issued Document: _______________________ Document Type: _______________________ Document ID: _______________________ Country/Authority that Issued Document: _______________________ Issuance Date: _______________________ Expiration Date: _______________________
Do you hold or have you held any nationality other than the one you have indicated above? Yes No Other Country/Region of Origin (Nationality): _______________________ Do you hold a passport from the country/region of origin (nationality) above? Yes No Passport Number: _______________________
Present Address: _______________________ City: _______________________ State/Province: _______________________ Postal Zone/ZIP Code: _______________________ Country/Region: _______________________ From Date: _______________________
Have you lived anywhere other than this address since the age of sixteen? Yes No Previous Address (1): _______________________ City: _______________________ State/Province: _______________________ Postal Zone/ZIP Code: _______________________ Country/Region: _______________________ From: _______________________ To: _______________________ Previous Address (2): _______________________ City: _______________________
State/Province: _______________________ Postal Zone/ZIP Code: _______________________ Country/Region: _______________________ From: _______________________ To: _______________________ Previous Address (3): _______________________ City: _______________________ State/Province: _______________________ Postal Zone/ZIP Code: _______________________ Country/Region: _______________________ From: _______________________ To: _______________________ Previous Address (4): _______________________ City: _______________________ State/Province: _______________________ Postal Zone/ZIP Code: _______________________ Country/Region: _______________________ From: _______________________ To: _______________________ Previous Address (5): _______________________ City: _______________________ State/Province: _______________________ Postal Zone/ZIP Code: _______________________ Country/Region: _______________________ From: _______________________ To: _______________________
Primary Phone Number: _______________________ Secondary Phone Number: _______________________ Work Phone Number: _______________________ Email Address: _______________________
Is your Mailing Address the same as your Present Address? Yes No Address: _______________________ City: _______________________ State/Province: _______________________ Postal Zone/ZIP Code: _______________________ Country/Region: _______________________
Do you have an address in the United States where you intend to live? Yes No Name of person currently living at address: _______________________ U.S. Address: _______________________ Phone Number: _______________________
Is this address where you want your Permanent Residence Card (Green Card) mailed? Yes No Contact Person: _______________________ Address: _______________________ City: _______________________ State: _______________________ ZIP Code: _______________________ Phone Number: _______________________
Family Information Father’s Surnames: _______________________ Father’s Given Names: _______________________ Date of Birth: _______________________ City of Birth: _______________________ State/Province of Birth: _______________________ Country/Region of Birth: _______________________ Is your father still living? Yes No Year of death: _______________________
Mother’s Surnames: _______________________ Mother’s Given Names: _______________________ Date of Birth: _______________________ City of Birth: _______________________ State/Province of Birth: _______________________ Country/Region of Birth: _______________________ Is your mother still living? Yes No Year of death: _______________________
Do you have any previous spouses? Yes No Previous Spouse Name (1): _______________________ Date of Birth: _______________________ Date of Marriage: _______________________ Date Marriage Ended: _______________________ How was your marriage terminated? _______________________ Country/Region where marriage was terminated: _______________________ Previous Spouse Name (2): _______________________ Date of Birth: _______________________ Date of Marriage: _______________________ Date Marriage Ended: _______________________ How was your marriage terminated? _______________________ Country/Region where marriage was terminated: _______________________
Number of Children: _______________________ Child Name (1): _______________________ Date of Birth: _______________________ City of Birth: _______________________ State of Birth: _______________________ Country/Region of Birth: _______________________ Does this child live with you? Yes No Address: _______________________ City: _______________________ State/Province: _______________________ Postal Zone/ZIP Code: _______________________ Country/Region: _______________________ Is this child immigrating to the U.S. with you? Yes No Is this child immigrating to the U.S. at a later date to join you? Yes No Child Name (2): _______________________ Date of Birth: _______________________ City of Birth: _______________________ State of Birth: _______________________ Country/Region of Birth: _______________________ Does this child live with you? Yes No Address: _______________________ City: _______________________ State/Province: _______________________ Postal Zone/ZIP Code: _______________________ Country/Region: _______________________ Is this child immigrating to the U.S. with you? Yes No Is this child immigrating to the U.S. at a later date to join you? Yes No Child Name (3): _______________________ Date of Birth: _______________________ City of Birth: _______________________ State of Birth: _______________________ Country/Region of Birth: _______________________ Does this child live with you? Yes No Address: _______________________ City: _______________________ State/Province: _______________________ Postal Zone/ZIP Code: _______________________ Country/Region: _______________________ Is this child immigrating to the U.S. with you? Yes No Is this child immigrating to the U.S. at a later date to join you? Yes No Child Name (4): _______________________ Date of Birth: _______________________ City of Birth: _______________________ State of Birth: _______________________ Country/Region of Birth: _______________________ Does this child live with you? Yes No Address: _______________________ City: _______________________ State/Province: _______________________ Postal Zone/ZIP Code: _______________________ Country/Region: _______________________ Is this child immigrating to the U.S. with you? Yes No Is this child immigrating to the U.S. at a later date to join you? Yes No Child Name (5): _______________________ Date of Birth: _______________________ City of Birth: _______________________ State of Birth: _______________________ Country/Region of Birth: _______________________ Does this child live with you? Yes No Address: _______________________ City: _______________________ State/Province: _______________________ Postal Zone/ZIP Code: _______________________ Country/Region: _______________________ Is this child immigrating to the U.S. with you? Yes No Is this child immigrating to the U.S. at a later date to join you? Yes No
Previous U.S. Travel Information Have you even been in the U.S.? Yes No Where you issued an Alien Registration Number by the Department of Homeland Security? Yes No Alien Registration Number: _______________________
Provide information on your last five U.S. visits. Date Arrived (1): _______________________ Length of Stay: _______________________ Date Arrived (2): _______________________ Length of Stay: _______________________ Date Arrived (3): _______________________ Length of Stay: _______________________ Date Arrived (4): _______________________ Length of Stay: _______________________ Date Arrived (5): _______________________ Length of Stay: _______________________
Have you even been issued a U.S. Visa? Yes No Date Visa Was Issued: _______________________ Visa Classification: _______________________ Visa Number: _______________________
If you answer yes to any of the following questions, please explain below: Have any of your U.S. visas ever been lost or stolen? Yes No Have any of your U.S. visas ever been cancelled or revoked? Yes No Have you ever been refused a U.S. visa, been refused admission to the U.S., or withdrawn your application for admission at the port of entry? Yes No If you answered yes to any of these questions, please explain: ____________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Work, Education, and Training Information Primary Occupation: _______________________ Do you have any other occupations? Yes No Other Occupations: _______________________ In which occupation do you intend to work in the U.S.: _______________________
Were you previously employed? Yes No Employer Name (1): _______________________ Employer Street Address: _______________________ City: _______________________ State/Province: _______________________ Postal Zone/ZIP Code: _______________________ Country/Region: _______________________ Telephone Number: _______________________ Job Title: _______________________ Supervisor’s Surnames: _______________________ Supervisor’s Given Names: _______________________ Employment Date From: _______________________ Employment Date To: _______________________ Employer Name (2): _______________________ Employer Street Address: _______________________ City: _______________________ State/Province: _______________________ Postal Zone/ZIP Code: _______________________ Country/Region: _______________________ Telephone Number: _______________________ Job Title: _______________________ Supervisor’s Surnames: _______________________ Supervisor’s Given Names: _______________________ Employment Date From: _______________________ Employment Date To: _______________________ Employer Name (3): _______________________ Employer Street Address: _______________________ City: _______________________ State/Province: _______________________ Postal Zone/ZIP Code: _______________________ Country/Region: _______________________ Telephone Number: _______________________ Job Title: _______________________ Supervisor’s Surnames: _______________________ Supervisor’s Given Names: _______________________ Employment Date From: _______________________ Employment Date To: _______________________ Employer Name (4): _______________________ Employer Street Address: _______________________ City: _______________________ State/Province: _______________________ Postal Zone/ZIP Code: _______________________ Country/Region: _______________________ Telephone Number: _______________________ Job Title: _______________________ Supervisor’s Surnames: _______________________ Supervisor’s Given Names: _______________________ Employment Date From: _______________________ Employment Date To: _______________________ Employer Name (5): _______________________ Employer Street Address: _______________________ City: _______________________ State/Province: _______________________ Postal Zone/ZIP Code: _______________________ Country/Region: _______________________ Telephone Number: _______________________ Job Title: _______________________ Supervisor’s Surnames: _______________________ Supervisor’s Given Names: _______________________ Employment Date From: _______________________ Employment Date To: _______________________
Have you attended any educational institutions at a secondary level or above? Yes No Number of Educational Institutions Attended: _______________________ Name of Institution (1): _______________________ Address of Institution: _______________________ City: _______________________ State/Province: _______________________ Postal Zone/ZIP Code: _______________________ Country/Region: _______________________ Course of Study: _______________________ Degree or Diploma: _______________________ Date of Attendance From: _______________________ Date of Attendance To: _______________________ Name of Institution (2): _______________________ Address of Institution: _______________________ City: _______________________ State/Province: _______________________ Postal Zone/ZIP Code: _______________________ Country/Region: _______________________ Course of Study: _______________________ Degree or Diploma: _______________________ Date of Attendance From: _______________________ Date of Attendance To: _______________________
Have you ever served in the military? Yes No Name of Country/Region: _______________________ Branch of Service: _______________________ Rank/Position: _______________________ Military Specialty: _______________________ Date of Service From: _______________________ Date of Service To: _______________________
Petitioner Information Petitioner is my: _______________________ Petitioner Name: _______________________ Petitioner Address: _______________________ City: _______________________ State/Province: _______________________ Postal Zone/ZIP Code: _______________________ Country/Region: _______________________ Telephone: _______________________ Mobile/Cell Telephone: _______________________ Email Address: _______________________
Security and Background Information •
Do you have a communicable disease of public health significance such as tuberculosis (TB)? Yes No
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Do you have documentation to establish that you have received vaccinations in accordance with U.S. law? Yes No •
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? Yes No •
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Have you ever been arrested or convicted for any offense or crime, even though subject or a pardon, amnesty, or other similar action? Yes No •
Have you ever violated, or engaged in a conspiracy to violate, any law relating to controlled substances? Yes No •
substance trafficking law, and have knowingly benefited from the trafficking activities in the past five years? Yes No •
vice or have you been engaged in prostitution or procuring prostitutes within the past 10 years? Yes No •
Yes No •
Have you ever committed or conspired to commit a human trafficking offense in the United States or outside the United States? Yes No •
Have you ever knowingly aided, abetted, assisted, or colluded with an individual who has been identified by the President of the United States as a person who plays a significant role in a severe form of trafficking in persons? Yes No •
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? Yes No •
Do you seek to engage in espionage, sabotage, export control violations, or any other illegal activity while in the United States? Yes No
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Do you seek to engage in terrorist activities while in the United States or have you ever engaged in terrorist activities? Yes No •
terrorist organizations? Yes No •
Are you a member or representative of a terrorist organization? Yes No •
Have you ever ordered, incited, committed, assisted, or otherwise participated in genocide? Yes No •
Yes No •
Have you committed, ordered, incited, assisted, or otherwise participated in extrajudicial killings, political killings, or other acts of violence? Yes No
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Have you ever engaged in the recruitment of or the use of child soldiers? Yes No
• Have you, while serving as a government official, been responsible for or directly carried out, at any time, particularly severe violations of religious freedom? Yes No •
Are you a member of or affiliated with the Communist or other totalitarian party? Yes No •
known as the Revolutionary Armed Forces of Columbia (FARC), National Liberation Army (ELN), or United Self-Defense Forces of Columbia (AUC)? Yes No •
gain, confiscated or expropriated property in a foreign nation to which a United States national had claim of ownership? Yes No •
governmental or political position converted for personal gain, confiscated or expropriated property in a foreign nation to which a United States national had claim of ownership? Yes No •
Have you ever been directly involved in the establishment or enforcement of 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 choice? Yes No •
Have you ever disclosed or trafficked in confidential U.S. business information obtained in connection with U.S. participation in the Chemical Weapons Convention? Yes No
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Are you the spouse, minor child, or agent of an individual who has disclosed or trafficked in confidential U.S. business information obtained in connection with U.S. participation in the Chemical Weapons Convention? Yes No
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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? Yes No •
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Have you failed to attend a hearing on removability or inadmissibility within the last five years? Yes No
• Have you ever been unlawfully present, overstayed the amount of time granted by an immigration official or otherwise violated the terms of a U.S. visa? Yes No
• Are you subject to a civil penalty under INA 274C? Yes No
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Have you been ordered removed from the U.S. during the last five years? Yes No
• Have you been ordered removed from the U.S. for a second time within the last 20 years? Yes No •
Have you ever been unlawfully present and ordered removed from the U.S. during the last ten years? Yes No
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Have you ever been convicted of an aggravated felony and been ordered removed from the U.S.? Yes No
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Have you ever been unlawfully present in the U.S. for more than 180 days (but no more than one year) and have voluntarily departed the U.S. within the last three years? Yes No •
year in the aggregate at any time during the last 10 years? Yes No
• 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? Yes No •
Have you ever intentionally assisted another person in withholding custody of a U.S. citizen child outside the United States from a person granted legal custody by a U.S. court? Yes No •
Have you voted in the United States in violation of any law or regulation? Yes No
• Have you ever renounced United States citizenship for the purpose of avoiding taxation? Yes No •
Have you attended a public elementary school or a public secondary school on student (F) status after November 30, 1996 without reimbursing the school? Yes No
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Do you seek to enter the United States for the purpose of performing skilled or unskilled labor but have not yet been certified by the Secretary of Labor? Yes No
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Are you a graduate of a foreign medical school seeking to perform medical services in the United States but have not yet passed the National Board of Medical Examiners examination or its equivalent? Yes No •
Are you a health care worker seeking to perform such work in the United States but have not yet received certification from the Commission on Graduates of Foreign Nursing Schools or from an equivalent approved independent credentialing organization? Yes No •
Are you permanently ineligible for U.S. citizenship? Yes No
• Have you ever departed the United States in order to evade military service during a time of war? Yes No
• Are you coming to the U.S. to practice polygamy? Yes No
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Are you a former exchange visitor (J) who has not yet fulfilled the two-year foreign residence requirement? Yes No
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Has the Secretary of Homeland Security of the United States ever determined that you knowingly made a frivolous application for asylum? Yes No
• Are you likely to become a public charge after you are admitted to the United States? Yes No
If you answer yes to any of the following questions, please explain below:__________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Social Security Number Information Have you every applied for a Social Security number? Do you want the Social Security Administration to issue a Social Security number and a card? Do you authorize disclosure of information from this form to the Department of Homeland Security, the Social Security Administration, and such other U.S. Government agencies as may be required for the purposes of assigning you a Social Security number (SSN) and issuing you a Social Security card and do you authorize the Social Security Administration to share your SSN with the Department of Homeland Security? Yes
Yes Yes
No No
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