面签领馆北京上海沈阳成都广州

1、面签领馆：北京 上海 沈阳 成都 广州 请您仔细阅读此提醒：表格内容不能有空项，如遇到没有的情况请填写“无”或写明为何不填写原因。否则则视为不合格申请表，并打回重新提供。此会耽误您的处理与预约面谈时间，请您重视并将表格填写完整。中青旅签证受理表（面试）淘宝ID(遨游可不填)订单号请您填写此次与您一同办理签证所有办理人信息，此受理表提供一份即可，如行数不够请自行添加办理人姓名护照号身份证号联系方式办理数量目的地旅游城市出行时间年月日请您选择未来两个月内，您不能面试的时间代传递统无需填写领取方式（请选）使馆直接寄送(面试后3-5工作日) 【请您将邮寄地址写全】中信银行自取(面试后5-7工作日)【例

2、：XX支行-XX区-具体地址】我方代取配送（需增加50元代取费用和支付快递费用，面试后9-11工作日）自取中信银行地址/使馆直接邮寄地址代传递统一为我司代取无需填写办理人邮箱（必填）如您购买的是拒签全退套餐，请您务必确认是否符合以下内容（请确认）如未确认，则视为不符合拒签全退条件。无美国拒签记录 五年内有英国或申根或加拿大或美国出入境记录（如有请随同资料提供相应的签证页）提供真实的送签资料已购买拒签全退套餐目前处于非孕期的申请美国签证没有不良出境记录（例如，境外逾期停留或没有其他国家身份的子女） 美国签证申请DS160信息表（请如实、详尽填写以下信息，如不符合本人情况，请填“无”，勾选信息可注

3、颜色或用标示；请提供英文谢谢）Personal, Address, Phone, and Passport/Travel Document InformationName Provided:Full Name in Native Language:Other Names Used:Telecode Name Used:Telecode NameSex:Marital Status:Date of Birth:Place of Birth:Country/Region of Origin (Nationality):Do you hold or have you held any nationa

4、lity other than the one indicated above on nationality?yes/noAre you a permanent resident of a country/region other than your country/region of origin (nationality) above?yes/noNational Identification Number:U.S. Social Security Number:U.S. Taxpayer ID Number:Home Address:City:State/Province:Postal

5、Zone/ZIP Code:Country/Region:Same Mailing Address?yes/noPrimary Phone Number:Secondary Phone Number:Work Phone Number:Email Address:Passport/Travel Document Type:Passport/Travel Document Number:Passport Book Number:Country/Authority that Issued Passport/Travel Document:City Where Issued:State/Provin

6、ce Where Issued:Country/Region Where Issued:Issuance Date:Expiration Date:Have you ever lost a passport or had one stolen?if yes,passport number : reason:yes/noTravel InformationThe List of Purposes of Trip to the U.S.Purpose of Trip to the U.S. (1):Specify:Have you made specific travel plans?yes/no

7、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:Are there other persons traveling with you?yes/noAre you traveling as part of a group or organization?yes/noPersons Traveling with You:Name (1):Relationship to You:Have

8、 you ever been in the U.S.? yes/noDate Arrived (1): Length of Stay: Date Arrived (2):Length of Stay: Do you or did you hold a U.S. Driver's License? If yes，number：yes/noHave you ever been issued a U.S. Visa? yes/noDate Last Visa was Issued: Visa Number: Are you applying for the same type of visa

9、? yes/noAre you applying in the same country where the visa above is issued and is this country your principal country of residence?yes/noHave you been tenprinted?yes/noHas your U.S. Visa ever been lost or stolen?yes/noHas your U.S. Visa ever been cancelled or revoked? yes/noYour Personal Copy Do No

10、t Bring to Interview Have you ever been refused a U.S. Visa, or been refused admission to the United States, or withdrawn your application for admission at the port of entry?yes/noHas anyone ever filed an immigrant petition on your behalf with the United States Citizenship and Immigration Services?y

11、es/noHave you ever been in the U.S.?yes/noHave you ever been issued a U.S. visa?yes/noHave you ever been refused a U.S. Visa, or been refused admission to the United States, or withdrawn your application for admission at the port of entry?yes/noHas anyone ever filed an immigrant petition on your beh

12、alf with the United States Citizenship and Immigration Services?yes/noU.S. Contact InformationContact Person Name in the U.S.:Organization Name in the U.S.:Relationship to You:U.S. Contact Address:Phone Number:Email Address:Family InformationFather's Surnames:Father's Given Names:Father'

13、s Date of Birth:Is your father in the U.S.?yes/noMother's Surnames:Mother's Given Names:Mother's Date of Birth:Is your mother in the U.S.?yes/noDo you have any immediate relatives, not including parents in the U.S.?if yes, name: relationship: status: nonimmigrant /permanent/other/US citi

14、zenyes/noDo you have any other relatives in the United States?yes/noSpouse's Full Name:Spouse's Date of Birth:Spouse's Country/Region of Origin (Nationality):Spouse's City of Birth:Spouse's Country/Region of Birth:Spouses Address:marriage date(D/M/Y)divorce date(D/M/Y)divorce rea

15、son:Work/Education/Training InformationPrimary Occupation:Present Employer or School Name:Address:City:State/Province:Postal Zone/Zip Code:Country/Region:Work Phone Number:Monthly Salary in Local Currency (if employed):Briefly Describe your Duties:Were you previously employed?yes/noEmployer Name (1)

16、:City:State/Province:Postal Zone/Zip Code:Country/Region:Telephone Number:Job Title:Supervisor's Surname:Supervisor's Given Name:Employment Date From:Employment Date To:Briefly describe your duties:Have you attended any educational institutions at a secondary level or above?yes/noName of Ins

17、titution (1):Address of Institution:City:State/Province:Postal Zone/ZIP Code:Country/Region:Course of Study:Date of Attendance From:Date of Attendance To:Do you belong to a clan or tribe?yes/noProvide a List of Languages You Speak:Language Name (1):Have you traveled to any countries/regions within t

18、he last five years?yes/noHave you belonged to, contributed to, or worked for any professional, social, or charitable organization?yes/noDo you have any specialized skills or training, such as firearms, explosives, nuclear, biological, or chemical experience?yes/noHave you ever served in the military

19、? (1.service time:from D/M/Y to D/M/Y 2.military rank: 3. speciality )yes/noHave you ever served in, been a member of, or been involved with a paramilitary unit, vigilante unit, rebel group, guerrilla group, or insurgent organization?yes/noSecurity and Background InformationDo you have a communicabl

20、e disease of public health significance? (Communicable diseases of public significance include chancroid, gonorrhea, granuloma inguinale, infectious leprosy, lymphogranuloma venereum, infectious stage syphilis, active tuberculosis, and others diseases as determined by the Department of Health and Hu

21、man Services.)yes/noDo 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/noAre you or have you ever been a drug abuser or addict?yes/noHave you ever been arrested or convicted for any offense or crime, even though subje

22、ct of a pardon, amnesty, or other similar action?yes/noHave you ever violated, or engaged in a conspiracy to violate, any law relating to controlled substances?yes/noAre you coming to the United States to engage in prostitution or unlawful commercialized vice or have you been engaged in prostitution

23、 or procuring prostitutes within the past 10 years?yes/noHave you ever been involved in, or do you seek to engage in, money laundering?yes/noHave you ever committed or conspired to commit a human trafficking offense in the United States or outside the United States?yes/noAre you the spouse, son, or

24、daughter of an individual who has committed or conspired to 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/noHave you knowingly aided, abetted, assisted or colluded

25、with an individual who has committed or conspired to commit a severe human trafficking offense in the United States or outside the United States?yes/noDo you seek to engage in espionage, sabotage, export control violations, or any other illegal activity while in the United States?yes/noDo you seek t

26、o engage in terrorist activities while in the United States or have you ever engaged in terrorist activities?yes/noHave you ever or do you intend to provide financial assistance or other support to terrorists or terrorist organizations?yes/noAre you a member or representative of a terrorist organiza

27、tion?yes/noHave you ever ordered, incited, committed, assisted, or otherwise participated in genocide?yes/noHave you ever committed, ordered, incited, assisted, or otherwise participated in torture?yes/noHave you committed, ordered, incited, assisted, or otherwise participated in extrajudicial killi

28、ngs, political killings, or other acts of violence?yes/noHave you ever engaged in the recruitment or the use of the child soldiers?yes/noHave you, while serving as a government official, been responsible for or directly carried out, at any time, particularly severe violations of religious freedom?yes/noHave you ever been directly involved in the establishment or enforcement of the population controls forcing a woman to undergo an abortion against her free choice or a man or a woma