Culomania

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SUPPLEMENTAL NONIMMIGRANT VISA APPLICATION
1. Last Name(s) (List all Spellings) 2. First Name(s) (List all Spellings)

U.S. Department of State

Approved OMB 1405-0134 Expires 09/30/2008Estimated Burden 1 Hour*

PLEASE TYPE OR PRINT YOUR ANSWERS IN THE SPACE PROVIDED BELOW EACH ITEM PLEASE ATTACH AN ADDITIONAL SHEET IF YOU NEED MORE SPACE TO CONTINUE YOUR ANSWERS 3. Full Name (In NativeAlphabet)

4. Clan or Tribe Name (If Applicable)

5. Spouse's Full Name (If Married)

6. Father's Full Name

7. Mother's Full Name

8. Full Name and Address of Contact Person or Organizationin the United States (Include Telephone Number)

9. List All Countries You have Entered in the Last Ten Years (Give the Year of Each Visit)

10. List All Countries That Have Ever Issued You aPassport

11. Have you ever lost a passport or had one stolen? Yes No

12. Not Including Current Employer, List Your Last Two Employers Address Telephone Number Name

Job Title

Supervisor's NameDates of Employment

13. List all Professional, Social and Charitable Organizations to Which You Belong (Belonged) or Contribute (Contributed) or with Which You Work (Have Worked).

14. Do youhave any specialized skills or training, including firearms, explosives, nuclear, biological, or chemical experience? No If YES, please explain Yes

15. Have you ever performed military service?Yes

No If yes, give name of country, branch of service, rank/position, military specialty, and dates of service.

16. Have you ever been in an armed conflict, either as a participant or victim?Yes

No

If YES, please explain.

17. List all educational institutions you attend or have attended. Include vocational institutions but not elementary schools. Address/Telephone Number Nameof Institution Course of Study

Dates of Attendance

18. Have you made specific travel arrangements?

Yes

No

If YES, please provide a complete itinerary for your travel, including...
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