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iApplication-SensitiveButUnclassiWedonotneedaprintedcopyofyourapplicationatanypointduringyourinterviewprocess.Onlyprintthisapplicationifyouwantacopyforyourownrecords.Ifyouprintyourapplication,pleasekeepitsecure.PhotoConfirmatonYourPersonalCopy--DoNotBringtoName LV,FullNamenNative OtherNames TelecodeName Teecode 0712, Marital DateofB 06MAYPlaceof Country/RegonofOrign(Natona Doyouholdorhaveyouheldanynatonaityotherthanthe oneindicatedaboveonnationalty?NationalIdentification U.S.SocaSecurity DOESNOTU.S.TaxpayerID DOESNOTHome 37XUEYUANC State/Prov DOESNOTPostaZone/ZIP SameMailing PrmaryPhone SecondaryPhone DOESNOTWorkPhone Emal Passport/TraveDocument Exp PASSPORTFORPUBLICPassport/TraveDocument PassportBook DOESNOTCountry/AuthoritythatIssuedPassport/TraveDocument: CtyWhereIssued: Country/RegionWhere Issuance 19SEPTEMBERExpration 19SEPTEMBERHaveyoueverlostapassportorhadone TravelTheLstofPurposesofTriptotheU.S.PurposeofTrptotheU.S. TEMP.BUSINESSPLEASUREVISITOR BUSINESS&TOURISM(TEMPORARYHaveyoumadespecfctravelp IntendedDateofArrva 26JULYIntendedLengthofStayn 12Addresswhereyouwllstayinthe 2001SOUTHFIRSTPerson/EntityPayingforYour Company/OrganzationPayngfortheTrip: TeephoneNumber: Relatonshpto AddressofCompany/OrganizationPaying: 37XUEYUANROAD DOESNOTPostalZone/ZIP Arethereotherpersonstravelingwith Areyoutravelingaspartofagroupororgan NameoftheGroup: MANAGEMENTTRAININGPROGRAMHaveyoueverbeenntheU.S.? DateArrved 14NOVEMBERLengthof 12DoyouorddyouhodaU.S.DriversL HaveyoueverbeenssuedaU.S.Vsa? DateLastVsawas 24JUNEVisa Areyouappyngforthesametypeofv Areyouappynginthesamecountrywherethevisaabovesssuedandsthscountryyourprncpalcountryofresidence?
Haveyoubeenten-pr HasyourU.S.Vsaeverbeenlostorsto HasyourU.S.Vsaeverbeencancelledor HaveyoueverbeenrefusedaU.S.Visa,orbeenrefused admissiontotheUnitedStates,orwthdrawnyourapplicatonforadmissionattheportofHasanyoneeverfiedanimmgrantpettiononyourbehalf wththeUntedStatesCtzenshpandImmigratonServices?ContactPersonNameinthe TRIPPIEDI,OrganzationNamenthe Relatonshpto U.S.Contact 2001SOUTHFIRSTSUITECHAMPAIGN,ILLINOISPhone Email strippie@illFamilyFathers FathersGiven HEFathersDateofB 04NOVEMBERIsyourfatherinthe Mothers MothersGiven LIMothersDateof 11DECEMBERIsyourmotherinthe Doyouhaveanymmedatereatives,notincludngparentsn theU.S.?DoyouhaveanyotherreativesntheUnited Primary PresentEmpoyerorSchool 37XUEYUAN DOESNOTPostalZone/Zip Country/Reg WorkPhone MonthySalaryinLocalCurrency(if BriefyDescrbeyourDuties: INTERNATIONALNETWORKINGMOBILITYPROGRAMSWereyouprevously Haveyouattendedanyeducationalinstitutionsatasecondaryevelorabove?
NameofInsttuton BEIJINGNORMALAddressof 19XINJIEKOUWAIC State/Prov DOESNOTPostaZone/ZIP Courseof ENGLISHDateofAttendance 10SEPTEMBERDateofAttendance 30JUNEDoyoubelongtoacanor ProvdeaListofLanguagesYouSpeak:LanguageName: LanguageName: Haveyoutraveedtoanycountreswithintheastfve Haveyoubeongedto,contrbutedto,orworkedforany professional,soca,orchartabeorganzaton?Doyouhaveanyspecializedskilsortraining,includng firearms,exposves,nucear,bioogical,orchemcalHaveyoueverservedinthem Haveyoueverservedin,beenamemberof,orbeennvolved withaparamitaryunt,vigilanteunit,rebegroup,guerrllagroup,ornsurgentorganizatDoyouhaveacommuncabediseaseofpublicheathsgnificance?(Communicablediseasesofpublc sgnificancencudechancroid,gonorrhea,granuomangunale,nfectousleprosy,lymphogranuomavenereum,infectiousstagesyphilis,actvetuberculosis,andothersdiseasesasdeterminedbytheDepartmentofHeathandHumanServces.)Doyouhaveamentalorphyscadisorderthatposesorslkelytoposeathreattothesafetyor welfareofyourseforothers?Areyouorhaveyoueverbeenadrugabuseroradd Haveyoueverbeenarrestedorconvictedforanyoffenseorcrime,eventhoughsubjectofapardon, amnesty,orothersmaraction?Haveyouevervioated,orengagednaconspiracytovolate,anylawreatingtocontrolled AreyoucomingtotheUnitedStatestoengageinprostitutionorunawfucommercazedviceorhave youbeenengagedinprostitutonorprocurngprostituteswithnthepast10years?Haveyoueverbeennvolvedin,ordoyouseektoengagein,money HaveyouevercommttedorconspiredtocommtahumantraffickngoffenseintheUntedStatesor outsidetheUntedStates?Areyouthespouse,son,ordaughterofanindvduawhohascommittedorconspiredtocommta humantraffickngoffenseintheUntedStatesoroutsidetheUnitedStatesandhaveyouwthintheastfveyears,knownglybeneftedfromthetraffckngactvHaveyouknowinglyaded,abetted,assistedorcoludedwithanndividuawhohascommittedor conspredtocommitaseverehumantraffickngoffenseintheUntedStatesoroutsidetheUnitedDoyouseektoengagenesponage,sabotage,exportcontrolviolations,oranyotherlegalactvty whilentheUnitedStates?DoyouseektoengagenterrorstactviteswheintheUnitedStatesorhaveyoueverengagedin terroristactivites?Haveyoueverordoyouintendtoprovdefnanciaassistanceorothersupporttoterroristsorterrorist organzations?Areyouamemberorrepresentativeofaterrorist Haveyoueverordered,incited,committed,assisted,orotherwiseparticipatedn Haveyouevercommtted,ordered,incited,assisted,orotherwiseparticipatedn Haveyoucommtted,ordered,incited,asssted,orotherwiseparticpatednextrajudicialkillngs, politcakllings,orotheractsofvoence?Haveyoueverengagedntherecrutmentortheuseofthechld Haveyou,wheservngasagovernmentofficial,beenresponsbleforordrectycarredout,atany time,particularlyseverevolatonsofregiousfreedom?Haveyoueverbeendirectlyinvovedintheestablishmentorenforcementofthepopulationcontrols forcingawomantoundergoanabortionagainstherfreechoiceoramanorawomantoundergosterilzationagainsthisorherfreeHaveyoueverbeendirectlyinvovedinthecoercvetransplantatonofhumanorgansorbodlytissue? Haveyoueverbeenthesubjectofaremovalordeportationhear Haveyoueversoughttoobtanorassistotherstoobtainavisa,entryntotheUnitedStates,orany otherUntedStatesimmigratonbeneftbyfraudorwlfumisrepresentatonorotherunlawfulmeans?Haveyoufaledtoattendahearingonremovabtyorinadmissibilitywthinthelastfive Haveyoueverbeenunawfullypresent,overstayedthe
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