U.S. Department of State
APPLICATION FOR IMMIGRANT VISA AND ALIEN REGISTRATION
OMB APPROVAL NO. 1405-0015 EXPIRES: 02/29/2012 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) Married Widowed Divorced times. Separated Including my present marriage, I have been married (Province) (Country)
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) Email 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) 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) 24. Mother's Family Name at Birth 25. Mother's Date of Birth (mm-dd-yyyy) 26. Place of Birth 21. Place of Birth First Name 22. Current Address Middle Name 23. If Deceased, Give Year of Death Middle Name 28. If Deceased, Give Year of Death First Name Middle Name
First Name 27. Current Address
DS-230 Part I 05-2009
This Form May be Obtained Free at Consular Offices of the United States of America Previous Editions Obsolete
Page 1 of 4
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...
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