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Nonimmigrant Visa Application

Application - Sensitive But Unclassified(SBU)

Photo Provided:

Confirmation N umber:

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Personal, Address, Phone, and Passport Informat ion

N am Provided: e Full N am in N ative Language: e Other N am Used: es Sex: M arital Status: Date of Birth: Place of Birth: N ationality: Other N ationalities: N ational Identification N um ber: U.S. Social Security N um ber: U.S. Taxpayer ID N um ber: H om Address: e City: State/Province: Postal Z one/Z IP Code: Country: Sam M ailing Address? e H om Phone N um e ber: Work Phone N um ber: Work Fax N um ber: M obile/Cell Phone N um ber: Em Address: ail Passport N um ber: Passport Book N um ber: Country/Authority that Issued Passport: City Where Issued: Country Where Issued: Issuance Date: Expiration Date: H ave you ever lost a passport or had one stolen? N GUYEN , N EN N GUYEN XUAN N EN NO M ALE M ARRIED 20 OCTOBER 1952 H AI DUON G , VIETN AM VIETN AM NO 250510395 DOES N OT APPLY DOES N OT APPLY 38 A H A GIAN G, LOC SON BAO LOC LAM DON G DOES N OT APPLY VIETN AM YES 633725226 DOES N OT APPLY DOES N OT APPLY 097538 28 49 [email protected] .sg B40248 62 DOES N OT APPLY VIETN AM DA LAT VIETN AM 13 APRIL 2010 13 APRIL 2020 NO

T ravel Informat ion

Principal Applicant? YES

Purpose of Your Trip to U.S. Purpose (1) : TOURIST/PERSON AL TRAVEL VISITOR (B2) 24 M AY 2010 1 M ON TH (S) 5118 S. KIM BARK AVE., APT 3E CH ICAGO, ILLIN OIS 60615 SELF YES NO N GUYEN , AN CH ILD

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:

Other Persons Traveling with You: Are you traveling as part of a group or organiz ation? Persons Traveling with You: N am (1) : e Relationship to You:

H ave you ever been in the U.S.? NO H ave you ever been issued a U.S. visa? NO H ave you ever been refused a U.S. Visa, been refused adm ission to N O the United States, or withdrawn your application for adm ission at the point of entry?

U.S. Cont act Informat ion

Contact Person N am in the U.S.: e Organiz ation N am in the U.S.: e Relationship to You: U.S. Contact Address: Phone N um ber: Em Address: ail N GUYEN , DUON G BROWN UN IVERSITY RELATIVE 5118 S. KIM BARK AVE., APT. 3E CH ICAGO, ILLIN OIS 60615 (917)499-6229 N H DUON GVN @GM AIL.COM

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