FORM DATA UNTUK PROSES VISA USA

NOTE :
1. Form ini HARUS diisi dengan lengkap dan jujur oleh peserta individu
2. Informasi dari formulir ini akan digunakan untuk pengisian formulir online permohonan Visa
USA. Apabila terjadi kesalahan pengisian formulir ini yang mengakibatkan visa di tolak, maka
hal ini di luar tanggung jawab kami

1. NAMA LENGKAP (SESUAI PASPOR) : ………………………………….......................

2. NAMA LAIN : ...........................................................................
3. TEMPAT / TANGGAL LAHIR : ...........................................................................
4. KEBANGSAAN : ...........................................................................
5. PERNAH PUNYA KEBANGSAAN LAIN
KEBANGSAAN NEGARA MANA: ............................................................................
SEJAK KAPAN : .............................................................................
6. NO KTP : ...........................................................................
7. NO PASPOR BARU : ...........................................................................
8. TEMPAT PEMBUATAN PASPORT : ...........................................................................
9. MASA BERLAKU PASPOR BARU : ...................................s/d....................................
10. APAKAH PASPORT ANDA PERNAH HILANG/DICURI, JIKA PERNAH SEBUTKAN ALASAN
:.................................................................................................................................................................
..................................................................................................................................................................
11. ALAMAT RUMAH LENGKAP : …………………………………........................
KODE POS :............................................................................
LAMA TINGGAL DI ALAMAT TERSEBUT :…..………………..............................................
NO. TELP RUMAH : ………………………………….......................
NO. TELP HP : ………………………………….......................
NO TELP KANTOR :............................................................................
NO FAX KANTOR :............................................................................
ALAMAT EMAIL : ………………………………...........................
12. APAKAH ADA FAMILY LAIN YANG IKUT KE USA : YA / TIDAK
- NAMA LENGKAP :............................................................................
- HUBUNGAN :............................................................................
- NAMA LENGKAP :............................................................................
- HUBUNGAN :............................................................................
13. TUJUAN PERGI KE USA :............................................................................
14. DATA KELUARGA

STATUS ANDA :………………………………….........................

NAMA SUAMI / ISTRI :.............................................................................

TEMPAT & TANGGAL LAHIR SUAMI / ISTRI : ............................................................................

KEBANGSAAN SUAMI /ISTRI : ............................................................................

ALAMAT & NO TELP SUAMI / ISTRI (CERAI) : ….......................................................................

NAMA AYAH : ............................................................................

TEMPAT & TANGGAL LAHIR AYAH : ............................................................................

APAKAH AYAH TINGGAL DI USA :.............................................................................

NAMA IBU : ............................................................................

TEMPAT & TANGGAL LAHIR IBU : ............................................................................

APAKAH IBU TINGGAL DI USA : ............................................................................
15. DATA PEKERJAAN / SEKOLAH

NAMA PERUSAHAAN /SEKOLAH : ...........................................................................

PERUSAHAAN BERGERAK DI BIDANG :............................................................................

JABATAN : ............................................................................

JELASKAN TUGAS DARI JABATAN ANDA : ............................................................................
..................................................................................................................................................................

LAMA BEKERJA : ..................................S/D....................................

ALAMAT PERUSAHAAN/SEKOLAH : ............................................................................
 KOTA : .............................................................................
PROPINSI : .............................................................................
KODE POS : .............................................................................

ALAMAT EMAIL PERUSAHAAN : ..............................................................................

SELAIN TEMPAT KERJA SEKARANG, DALAM 5 TAHUN TERAKHIR PERNAH
BEKERJA DI TEMPAT LAIN : YA / TIDAK
JIKA YA , ALAMAT PERUSAHAAN/SEKOLAH: ..............................................................................
KOTA : .............................................................................
PROPINSI : .............................................................................
KODE POS : .............................................................................
MASA BEKERJA : .............................S/D..........................................
JABATAN TERAKHIR : .............................................................................
DESKRIPSIKAN TUGAS TERAKHIR : ..............................................................................
NAMA LENGKAP ATASAN ANDA : .............................................................................
16. PENGHASILAN PER BULAN : ……………………………….............................
17. APAKAH ANDA PERNAH KE USA : YA / TIDAK
JIKA YA, KAPAN DAN BERAPA LAMA : ………………………………….........................
18. PERNAH MENGAJUKAN VISA : YA / TIDAK
JIKA YA TANGGAL BERAPA VISA DIKELUARKAN : ....................................................................
NOMOR VISA USA YANG PERNAH DIKELUARKAN: ....................................................................
19. VISA USA YANG DIAJUKAN PERNAH DITOLAK : YA / TIDAK
JIKA YA, KAPAN : ………………………………….........................
20. YANG MEMBIAYAI SELAMA DI US : ………………………………….........................
21. PERNAH ADA VISA LAIN YANG DITOLAK : YA / TIDAK
22. JIKA YA, VISA APA YANG PERNAH DITOLAK : .............................................................................
DAN KAPAN : ............................................................................
23. JIKA TUJUAN ANDA BISNIS, DALAM RANGKA APA : ................................................................
24. PERUSAHAAN DI USAYANG MENGUNDANG : ............................................................................
25. ALAMAT LENGKAP PERUSAHAAN YANG MENGUNDANG DI USA
DENGAN KODE POS : .....................................................................................................................
26. NO TELEPON PERUSAHAANYANG MENGUNDANG : .................................................................
27. ALAMAT EMAIL PERUSAHAAN YANG MENGUNDANG: ............................................................
28. BERAPA LAMA TINGGAL DI USA : ............................................................................
29. TANGGAL TIBA DI USA & FLIGHT YG DIGUNAKAN : ................................................................
..................................................................................................................................................................
30. TANGGAL KELUAR DARI URUS & FLIGHT YANG DIGUNAKAN :.............................................
..................................................................................................................................................................
31. SELAMA DI USA TINGGAL DIMANA : ............................................................................
32. NAMA HOTEL : ............................................................................
33. ALAMAT HOTEL LENGKAP DENGAN KODE POS: .......................................................................
LOKASI YANG AKAN DIKUNJUNGI DI USA : ...........................................................................
34. NO TELEPON HOTEL : ............................................................................
35. ALAMAT EMAIL / WEBSITE HOTEL : ............................................................................
36. PUNYA FAMILY / TEMAN DI USA : YA/TIDAK
37. NAMA FAMILY / TEMAN DI USA : ............................................................................
38. EMAIL FAMILY / TEMAN DI USA : ............................................................................
39. ALAMAT FAMILY / TEMAN DI USA
LENGKAP DENGAN KODE POS : ............................................................................
40. NO TELEPON FAMILY/ TEMAN DI USA :.............................................................................
41. HUBUNGAN DENGAN ANDA : ............................................................................
Jakarta, …............................
Nama dan Tanda Tangan Pemohon

( )
RIWAYAT SEKOLAH SEBELUMNYA :
1. TK

NAMA SEKOLAH : ............................................................................

ALAMAT SEKOLAH : …........................................................................

NO. TELEPON SEKOLAH : …........................................................................

KOTA : …........................................................................

PROPINSI : …........................................................................

KODE POS : …........................................................................

LAMA SEKOLAH : ..................................S/D....................................

2. SD

NAMA SEKOLAH : ............................................................................

ALAMAT SEKOLAH : …........................................................................

NO. TELEPON SEKOLAH : …........................................................................

KOTA : …........................................................................

PROPINSI : …........................................................................

KODE POS : …........................................................................

LAMA SEKOLAH : ..................................S/D....................................

3. SMP

NAMA SEKOLAH : ............................................................................

ALAMAT SEKOLAH : …........................................................................

NO. TELEPON SEKOLAH : …........................................................................

KOTA : …........................................................................

PROPINSI : …........................................................................

KODE POS : …........................................................................

LAMA SEKOLAH : ..................................S/D....................................

4. SMA

NAMA SEKOLAH : ............................................................................

ALAMAT SEKOLAH : …........................................................................

NO. TELEPON SEKOLAH : …........................................................................

KOTA : …........................................................................

PROPINSI : …........................................................................

KODE POS : …........................................................................

LAMA SEKOLAH : ..................................S/D....................................

5. UNIVERSITY

NAMA UNIVERSITY : ............................................................................

ALAMAT UNIVERSITY : …........................................................................

NO. TELEPON UNIVERSITY : …........................................................................

LAMA KULIAH : ..................................S/D....................................