EFTA00286277.pdf

25061321:25 Valdson Consuter Eleaftlk Application Center - Prim Application 0144170211 p.1 6( 18113 532 PM U.S. DEPARTMENT CONSULAR ELECTRONIC APPLICATION CENTER Online Nonimmigrant Visa Application (DS-160) Application - Sensitive But Unclassified(SBU) We do not need a printed copy of your application at any point during your interview process. Only print this application if you want a copy for your own records. If you print your application, please keep it secure. Photo Provided: Confirmation Number: a IgIR1110,11114111 Your Personal Copy -- Do Not Bring to Interview Personal, Address, Phone, and Passport/Travel Document Information Name Provided: Full Name In Native Language: Other Names Used: reiecode Name Used: Sex: Marital Status: Date of Birth: Place of Birth: Country/Region of Origin (Nationality): Do you hold or have you held any nationality other than the one indicated above on nationality? National Identification Number: U.S. Social Securely Number: U.S. Taxpayer ID Number: Home Address: City: State/Province: Postal Zone/ZIP Code: Country/Region: VIE:RA COTR:N, VALDSON VALDSON VIEIRA COTRIN MALE • mtp+ !;ceac.stae goviCenNIV/commonipontapplication.arpx7omiPifk9C5Xki0n0t2I6GpwaliN48IvDLIE2bEnmYk‘e-I912Kj0%3d Page 1 of 6 EFTA00286277 25 06 13 21:26 Valdson 0144170211 p.2 Consular Electronic Application Center - Print Application 6118/13522 PM Visa Number: Are you applying for the same type of visa? YES Are you applying in the same country where the visa above is Issued YES and is this country your principal country of residence? Have you been ten-printed? Has your U.S. Visa ever been lost or stolen? Has your U.S. visa ever been cancelled or revoked? Have you ever been refused a V.S. Visa, or been refused admission to the United States, or withdrawn your application for admission at the port of entry? Has anyone ever filed an immigrant petition on your behalf with the United States Citizenship and Immigration Services? U.S. Contact Information Contact Person Name in the U.S.: Organization Name in the U.S.: DO NOT KNOW Relationship to You: FRIEND U.S. Contact Address: Phone Number: Email Address: Family Information Father's Surnames: DO NOT KNOW Father's Given Names: DO NOT KNOW Mother's Surnames: Mother's Given Names: Mother's Date of Birth: DO NOT KNOW Is your mother In the U.S.? Do you have any immediate relatives, not including parents In the U.S.? Do you have any other relatives in the United States? Number of former spouses: Former Spouse's Name (1): Date of Birth: Country/Region of Origin (Nationality): Place of Birth City: Place of Birth Country/Region: Date of Marriage: Date Marriage Ended: How the Marriage Ended: Ittiorikeac.state.gov/CenNN/conenon/printapplicationaspOorn,Pk9C5Xkl0mX2f6Gerw4XAMSIvDu91214nmekvItHOL2KPAI3d Page 3 of 6 EFTA00286278 25 06 13 21:26 Valdson 0144170211 p.3 Consular Electronic Application Center - Print Application 6;16/13 532 PM Seine Melling Address? Primary 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: Country/Region Where Issued: Issuance Date: Expiration Date: Have you ever lost a passport or had one stolen? Travel Information "Jibe List of Purposes of Trip to the U.S. Purpose of Trip to the U.S. (1): Spedfy: Have you made spedfic travel plans? Intended Date of Arrival: Intended Length of Stay in U.S.: Address where you will stay in the U.S.: City, State, Postal/Zip Code: IM Person/Entity Paying for Your Trip: SELF Are there other persons traveling with you? YES Are you traveling as part of a group Or organization? ■ Persons Traveling with You: Name (1): Relationship to You: FR/END Lel. Have you ever been in the U.S.? YES Date Arrived (1): YES REGULAR • TEMP. BUSINESS PLEASURE VISITOR (B) TOURISM/PERSONAL TRAVEL (82) Length of Stay: Do you or did you hold a U.S. Driver's License? Have you ever been issued a U.S. Visa? Date Last Visa was Issued: 18 JULY 2013 3 WEEK(S) 2 WEEK(S) YES 29 OCTOBER 2002 ettps://cestitate-gov/CenNN/cornenon/prIntappfication.ascuOonuPPk9C5xIgCm142r6Cps4)0143ivDufahfnmlingH9L210:00g Page 2 of 6 EFTA00286279 25 06 13 21:27 Valdson 0144170211 p.4 Corse it klectrontc wooer:anon Center - Print Application 6(18(13 5:32 PM Have you ever committed or conspired to commit a human trafficking offense in the United States or outside the United States? Are you the spouse, son, or 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? Have you knowingly aided, abetted, assisted or colluded with an individual who has committed or conspired to commit a severe human trafficking offense in the United States or outside the United States? Do you seek to engage in espionage, sabotage, export control violations, or any other illegal activity while in the United States? Do you seek to engage in terrorist activities while in the United States or have you ever engaged in terrorist activities? Have you ever or do you intend to provide financial assistance or other support to terrorists or terrorist organizations? Are you a member or representative of a terrorist organization? Have you ever ordered, incited, committed, assisted, or otherwise participated In genocide? Have you ever committed, ordered, incited, assisted, or otherwise participated in torture? Have you committed, ordered, incited, assisted, or otherwise participated in extrajudicial killings, political killings, or other acts of violence? Have you ever engaged in the recruitment or the use of the child soldiers? Have you, while serving as a government official, been responstile for or directly carried out, at any time, particularly severe violations of religious freedom? Have 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 woman to undergo sterilization against his or her free will? Have you ever been directly involved in the coercive transplantation of human organs or bodily tissue? Have you ever been the subject of a removal or deportation hearing? Have you ever sought to obtain or assist others to obtain a visa, entry into the United States, or any other United States Immigration benefit by fraud or willful misrepresentation or other unlawful means? Have you failed to attend a hearing on removability or inadmissibility within the last five years? Have you ever been unlawfully present, overstayed the amount of time granted by an immigration official or otherwise violated the terms of a U.S. visa? nave you ever withheld custody of a U.S. citizen child outside the United States from a person granted legal custody by a U.S. court? Have you voted in the United States in violation of any law or regulation? Have you ever renounced United States citizenship for the purpose of avoiding taxation? Have you attended a public elementary school on student (F) status or a public secondary school after November 30, 1996 without reimbursing the school? Location Information Location where you will be submitting your application Current Location: BRASILIA. Preparer of Application Did anyone assist you in filling out this application? • Vett our Dei ran nni It" in RIM/ Rini. 12,4 ran to Mtn Mei LISA/ • • • • • • • • • httpsa +ceac.state.goviCenNIVicommonj onntaeptcallon.aspx?ornaPPk9C5XkiCm%2f6Gped4XNeStvDa%2Ignmekv8H9L214)1Oci Page_' of 6 EFTA00286280 25061321:27 Valdson 0144170211 p.5 Corg.ular Ctectronlc Apecation ante/ - Prim Application 6(1.8“3 5:32 PM • •••• Mie • • •./ • •••••• • • Ibn • ••• r y loue ••• a a lb OS, • •• • r a • • ••••••• IF • %OU' •Ir Assinou electronicamente a sua solicitação em 18-Jun-2013 11:38:04. Foi-lhe pedido para assinar electronicamente a sua solicitação, salvo esteja regulamentarmente isento, mesmo que a solicitação tenha sido preparada por outra pessoa. A sua assinatura electrónica certifica que leu e entendeu as perguntas nesta solicitação e que as suas respostas são verdadeiras e correctas melhor do seu conhecimento. A submissão de uma solidtação contendo quaisquer declarações falsas ou enganosas poderá resu ter na recusa permanente de um visto ou de entrada para os Estados Unidos. Todas as declarações feitas nesta solicitação são declarações nao ajuramentadas mas feitas sob pena de perjúrio. (28.U.S.C.1746) A Informação que forneceu na sua solicitação e outras informações submetida com a sua solicitação agencias governamentals que tenham autoridade legal para usarei tal informação, incluindo para prt criminal ou de Imigração. A fotografia que forneceu com a sua solicitação poderá ser usada para verdi propósitos de aplicação da lei Arnerlcana. derão ser acedidas por outras Sósitos de aplicação de lei ação de emprego ou outros https:/» ...eac state.gow/CenNiV/common/pnnupecadon.aspx?ornfr0k9CSXkjOmief6Cpri4XN461v0ufebtornYkr61191.2leffad Page 6 of 6 EFTA00286281 25 06 13 21:27 Valdson Colmar otntrOa;C APPIICAlktM Ceder - Print Application 0144170211 p.6 5/115(13 5 311,W. Country/Region Marriage was Terminated: Work/Education/Training Information Primary Occupation: OTHER Specify Other: MAITRE O HOTEL Present Employer or School Name: EPSTEIN JEFFREY Address: City: State/Province: Postal Zone/Zip Code: Country/Region: Work Phone Number: Monthly Salary In Local Currency (if employed): Briefly Describe your Duties: SERVIR A TABLE ENTRETIEN OE LA MAISON Were you previously employed? Have you attended any educational institutions at a secondary level or above? Do you belong to a clan or tribe? ff. Provide a List of Languages You Speak: Language Name: (I): PORTUGAIS FRNCAIS ANGLAIS Have you traveled to any countries within the last Ave years? Have you belonged to, contributed to, or worked for any professional, social, or charitable organization? Do you have any specialized skills or training, Including firearms, explosives, nuclear, biological, or chemical experience? Have you ever served in the military? Have you ever served in, been a member of, or been involved with a paramilitary unit, vigilante unit, rebel group, guerrilla group, or insurgent organization? Security and Background Information Do you have a communicable disease of public hearth 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 Human Services.) Do 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? Are you or have you ever been a drug abuser or addict? • • U U U U Have you ever been arrested or convicted for any offense or crime, even though subject of a pardon, amnesty, or other similar action? Have you ever violated, or engaged In a conspiracy to violate, any law relating to controlled substances? Are you coming to the United States to engage In prostitution or unlawful commercialized vice or have you been engaged In prostitution or procuring prostitutes within the past 10 years? Have you ever been Involved In, or do you seek to engage In, money laundering? hilos://cerc.start.sov/Ceniiivicommon/printappikation.aspoonuPPk9CSXklOmx2ISCor410448hOucabEnmvkletifit2igtend U U U U U U Page 4 of 6 EFTA00286282