US VISA APPLICATION

PERSONAL INFORMATION:
Surname: DE LEON
Given Name: MARREY ANNE
Middle Name: BAGANG
Sex: FEMALE
Marital Status: SINGLE
Date of Birth: SEPTEMBER 11, 1998
Place of Birth: MALOLOS, BULACAN
Nationality: FILIPINO
Do you hold or have you held any nationality other than the one indicated
above on nationality?_NO__
National Identification
N/A
Number:
U.S. Social Security
N/A
Number:
U.S. Taxpayer ID Number: N/A

ADDRESS & PHONE INFORMATION:

107 SITIO II, SAN JOSE, PAOMBONG, BULACAN
Home Address (complete):

Mailing Address: 107 SITIO II, SAN JOSE, PAOMBONG, BULACAN

Primary Phone Number: 09476071455
Secondary Phone Number: 09155181156
Work Phone Number: N/A
E-mail Address: deleon.marrey11@gmail.com

PASSPORT / TRAVEL DOCUMENT: (please attach a photocopy of your passport)

Passport/Travel Document Type: REGULAR
Passport/Travel Document Number: P4633330B
Passport Book Number: N/A FOR PHILIPPINE PASSPORTS
Country/Authority that Issued
PHILIPPINES
Passport/Travel Document:
City where issued: MALOLOS CITY
Country/Region where issued: PHILIPPINES
Issuance Date: JAN 29 2020
Expiration Date: JAN 29 2030

 Have you ever lost a passport or had one stolen? NO

TRAVEL INFORMATION:
Purpose of Trip to the U.S. (1): TEMP. BUSINESS PLEASURE VISITOR (B)
Specify: BUSINESS & TOURISM (TEMPORARY VISITOR) (B1/B2)
Intended Date of Arrival:JULY 22,2020
Intended Length of Stay in U.S.: 20 DAYS
Address where you will stay in the U.S.: 11999 Harbor Blvd, Garden Grove, CA 92840, United States

Name of Person/Entity Paying for Your Trip:

Telephone Number:
Email Address:
Relationship to You:
Payer's Address (complete):

Other Persons Traveling with You:YES

Are you traveling as part of a group or organization? YES
Name of the Group: WCOPA TEAM PHILIPPINES

 Have you ever been in the U.S.? _NO_

 Have you ever been issued a U.S. visa? NO (If yes, kindly provide photo of previous US visa and dates
of last 5 visits to the US)
 Have you ever been refused a U.S. Visa, or been refused admission to the United States, or withdrawn
your application for admission at theport of entry? __NO__
 Reason for denial (if denied previously) ?__N/A_________________________________________
 Has anyone ever filed an immigrant petition on your behalf with the United States Citizenship and
Immigration Services? ____N/A_____
 Have you ever travelled abroad? _____N/A______
 Countries you have visited in the past 5 years?_____N/A____________________________________

FAMILY INFORMATION:
Father’s Surname: DE LEON
Father’s Given Name: REYNALDO
Father’s Date of Birth: AUGUST 11, 1962
Is your Father in the US? NO
Mother’s Surname: DE LEON
Mother’s Given Name: MARITES
Mother’s Date of Birth: AUGUST 16, 1965
Is your Mother in the US? NO

 Do you have any immediate relatives, not including parents in the US?
o Relative Name: ____N/A__________________________________________________________
o Relationship to You:____N/A_________________________
o Status: (ex. US Citizen) __N/A______________________
 Do you have other relatives in the US? YES
(FOR MARRIED APPLICANTS)
Spouse’s Full Name: N/A
Spouse’s Date of Birth: N/A
Spouse’s Nationality: N/A
Spouse’s City of Birth: N/A
Spouse’s Country of Birth: N/A
Spouse’s Address: N/A

PRESENT WORK / SCHOOL:

Primary Occupation: STAFF
Present Employer or
SANGGUNIANG BAYAN NG PAOMBONG
School Name:
Address:
City:
State or Province:
Postal Zone/Zip Code:
Country:
Work Phone Number:
Monthly Salary (Pesos):

Briefly Describe your

Duties:

 Were you previously employed? __________

Employer Name:
Address (complete):
Telephone Number:
Job Title:
Supervisor’s Name:
Employment Date:
From: ___________________ To: ______________________
(mm/dd/yyyy)

Briefly Describe your

Duties:
 Have you attended any educational institutions at a secondary level or above? _________
High School
Name of Institution
Address
Province
Postal/Zip code
Date Attended:
From: ___________________ To: ______________________
(mm/dd/yyyy)

College
Name of Institution
Address
Province
Postal/Zip code
Date Attended:
From: ___________________ To: ______________________
(mm/dd/yyyy)

LINK TO YOUR SOCIAL MEDIA PAGES:

FACEBOOK:
INSTAGRAM:
YOUTUBE:
TWITTER:
OTHERS:

SECURITY AND BACKGROUND INFORMATION: (Yes or No)

1. Do you have a communicable disease of public health significance? (Communicable diseases of public
significance include chancroid, gonorrhea, granuloma inguinale, infectious leprosy, lymphogranuloma
venereum, infectious stage syphilis, active tuberculosis, and other diseases as determined by theDepartment of
Health and Human Services.) _______

2. 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? _______

3. Are you or have you ever been a drug abuser or addict? _______

4. Have you ever been arrested or convicted for any offense or crime, even though subject of a pardon, amnesty,
or other similar action? _______

5. Have you ever violated, or engaged in a conspiracy to violate, any law relating to controlled substances? _______

6. 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? _______

7. Have you ever been involved in, or do you seek to engage in, money laundering? _______

8. Have you ever committed or conspired to commit a human trafficking offense in the United States or outside
the United States? _______
9. 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 lastfive years,
knowingly benefited from the trafficking activities? _______

10. 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 UnitedStates? _______

11. Do you seek to engage in espionage, sabotage, export control violations, or any other illegal activity while in the
United States? _______

12. Do you seek to engage in terrorist activities while in the United States or have you ever engaged in terrorist
activities? _______

13. Have you ever or do you intend to provide financial assistance or other support to terrorists or terrorist
organizations? _______

14. Are you a member or representative of a terrorist organization?

15. Have you ever ordered, incited, committed, assisted, or otherwise participated in genocide? _______

16. Have you ever committed, ordered, incited, assisted, or otherwise participated in torture? _______

17. Have you committed, ordered, incited, assisted, or otherwise participated in extrajudicial killings, political
killings, or other acts of violence? _______

18. Have you ever engaged in the recruitment or the use of the child soldiers? _______

19. Have you, while serving as a government official, been responsible for or directly carried out, at any time,
particularly severe violations of religious freedom? _______

20. 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 undergosterilization against his
or her free will? _______

21. Have you ever been directly involved in the coercive transplantation of human organs or bodily tissue? _______

22. 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? _______

23. Have 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? _______

24. Have you voted in the United States in violation of any law or regulation? _______

25. Have you ever renounced United States citizenship for the purpose of avoiding taxation? _______