Deterministic Data Instruction

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
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. The fee should be paid in United States dollars or local currency equivalent, or by bank draft. Warning: Any false statement or concealment of a material fact may result in your permanent exclusion from the United States. Even if you are issued an immigrant visa and are subsequently admitted to the United States, providing false information on this form could be grounds for your prosecution and/or deportation. This form (DS-230 Part II), together with Form DS-230 Part I, constitutes the complete Application for Immigrant Visa and Alien Registration. 36. Family Name First Name Middle Name 37. Other Names Used or Aliases (If married woman, give maiden name) 38. Full Name in Native Alphabet (If Roman letters not used) 39. Name and Address of Petitioner Telephone number Email Address 40. United States laws governing the issuance of visas require each applicant to state whether or not he or she is a member of any class of individuals excluded from admission into the United States. The excludable classes are described below in general terms. You should read
I understand that any willfully false or misleading statement or willful concealment of a material fact made by me herein may subject me to permanent exclusion from the United States and, if I am admitted to the United States, may subject me to criminal prosecution and/or deportation. I, the undersigned applicant for a United States immigrant visa, do solemnly swear (or affirm) that all statements which appear in this application, consisting of Form DS-230 Part I and Part II combined, have been made by me, including the answers to items 1 through 45 inclusive, and that they are true and complete to the best of my knowledge and belief. I do further swear (or affirm) that, if admitted into the United States, I will not engage in activities which would be prejudicial to the public interest, or endanger the welfare, safety, or security of the United States; in activities which would be prohibited by the laws of the United States relating to espionage, sabotage, public disorder, or in other activities subversive to the national security; in any activity a purpose of which is the opposition to or the control, or overthrow of, the Government of the United States, by force, violence,