apanor7 Consular Electronic Applicaton Center - Pris Application 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 copy for your own records. Ifyou print your application, please keep it Photo Provided Photowill be taken at the ASC. Confirmation Number: AACOGWOELY Your Personal Copy -- Do Not Bring to Interview Personal, Address, Phone, and Passport/Travel Document Information Name Provides Full Name ip Nate Language: (Otner Names Used Telecode Name Uses Sex Marital Status Date of Birth Country/Region of Origin (Nationality) De you nok ar have you hel any natonlty ater then he one ‘Are you a permanent resident ofa country/region other than your Coucey/remion of onan (nabanalty) above? US. Taxpayer 1D Numbe! wy State/Province Postal Zane/Z1P Code: Country/Region: Same Mailing Address? Primary Phone Number: Secondary Phone Number: Work Phone Number Inpevinae state goviGenNIVicommonrintapglicstion aspx?82U x8H9M OES Nor APPLY No No mae SINGLE 07 suty 1988, PUNE, MAHARASHTRA, INDIA MAHARASHTRA 421008 ino ves 02025487036 9527699519 DOES Nor APPLY NO‘42b2ie pote aba W/VVTZMEiqhurXKUVSA%IG our interview process. Only print this application if you want a 16ana017 Email Address Passport Travel Document Type: Passport Travel Document Number: Passport Book Number: Country/Authorty that Issued Passpor/Travel Document: City Where tssued Country/Region Where resus: Issuance Date ei Have you ever lost @ passport ar ha one stolen? tion Date: Travel Information The Uist of Purposes of Tip tothe US. Purpose of Tip to the WS. (2): Specty Have you made specific travel plans? Intended Oate of Arival Intended Length of Stay in US. Adress where you wil stay in the US. Person/Entty Paying for Your Trp CCompany/Organzation Paying for te Tie ‘Telephone Number: Relationship to You Adress of Company/Organization Paying ow State/Province Postal Zone/ZIP Code Country/Region Are there other persons traveling with you? Have you ever been in the U.S.7 Date arrives (1) Length of Stay Date Arrived (2) Length of Stay pate Arrived (2) Length of stay you or did you hold a US. Driver's License? Have you ever been issued 2 U.S. Visa? Date Last Visa was Issued Visa Number! Are you applying for the same type of visa? Are you appling in the same country where the visa above Is Issued ‘nd Is this country your principal country of residence? Have you been ten-printed? Has your US. Visa ever been lost oF stolen? Has your US. Vise ever been cancelled or revoked? Have you ever been refused a U.S. Vise, or been refused admission to'the United States, or withdrawn your application for admission at the port of enty? Has anyone ever fled an immigrant petition on your behalf withthe United States Cuzenship and Immigration Services? U.S. Contact Information Consular Electronic Applicaton Center - Prin Application skrilesh788@qmall.com REGULAR vana754 OES Nor APPLY N08 PUNE: ‘nora 10 FEBRUARY 2009 (09 FEBRUARY 2019, No ALIEN IN TRANSIT (C) ‘CREWMEMBER IN TRANSIT (C1/0} No 10 UNE 2017 2 0av(s) (ON BOARD THE SHIP CCOMPANY/ORGANIZATION ANGLO EASTERN SHIP MGMT 1 PVT LTO oaz61124600 EMPLOYER 303 LEELA BUSINESS PARK ANDHERI EAST momeal MAHARASHTRA 400058 NOTA No ves 01 DECEMBER 2016 3 00vis) says) ‘ox May 2015; avs) No ves 23 AUGUST 2012 3603965, ves ves ves No No No No hnpesienae state goviGenNIVicommorxntaglication aspxa82U:¥6H 9M TNO%K2b2Ie Vpb¥E4abaWWVTZMEiqkuXKUVSA%I6ana017 contact Parson Name Inthe US. Organization Name In the US. Relationship to You US. Contact Address Phone Number Email Address Family Information Father's Surnames: Father's Given Names: Fathers Date of Birth Is your Father in the U.S.7 Mothers Surnames: Mothers Given Nemes: others Date of Bit 1s your mother inthe U.5.7 1 you have any immediate relatives, not inchiding parents inthe De you nave any other retatves in the Unked States? Work/Education/Training Information Primary Occupation: Specty Otner: Present Employer or Scheal Name: Aadeess: cy statm/Province Postal Zone/Zip Code: Country/Region Work Phone Number: Monthly Salary in Local Currency (if employes) Briety Describe your Dut: Were you previously employed? Employer Name (1): Consular Electronic Applicaton Center - Prin Application JAR, HELAL ANGLO EASTERN SHIP MGMT EMPLOYER 20701 CORPORATE DRIVE SUITE 138 8 STAFFORD HOUSTON, TEXAS 77477 2oiz6s40i4 DOES Nor APPLY MAVLANKAR HENAN VASUDEV 24 AUGUST 1954 No MAVLANKAR PRADNYA HEMAN 06 APaIL 1959 No omner “SEAMAN - MARINE ENGINEER OFFICER ANGLO EASTERN SHIP MGMT 1 PYT LTO moment MAHARASHTRA, 400059 Noa 02261124600 280000 MARINE ENGINEER OFFICER ON FOREIGN GOING MERCHANT SHIPS. ‘OPERATION AND MAINTENANCE OF MARINE MACHINERY IN [XCCORDANCE WITH ALL INTERNATIONAL AND LOCAL REGULATIONS ‘BND COMPANY POLICIES, ves MAERSK LINE INDIA PTE LTD Employer Address: wy cy State/Province Postal Zone/Zip Code Country/Region: Telephone Number: sab Tite: Supervisors Surname: Supervisors Given Nome: Employment Date From: Employment Date To: hnpesienae state goviGenNIVicommorxntaglication aspxa82U:¥6H 9M TNO%K2b2Ie Vpb¥E4abaWWVTZMEiqkuXKUVSA%I6 seen oa +31 OCTOBER 2015ana017 Briefly describe your duties Employer Name (2): Employer Address: cy State/Province Postal Zone/Zip Code Country/Region Telephone Number: ob Tie Supervisor's Surname: Supervisors Given Name: Employment Date From Employment Date To: Briey describe your duties: Have you attendee any educational instutions at 2 secondary level br above? Name of Inststion (1): Adress of instton Co State/Province Postal Zone/2IP Code Country Region Course of Study Date of attendance From Do you belong to a clan or tbe? Provide a Ust of Languages You Speak Language Name (2: Language Name (2): Language Name (3): Have you taveled to any countriesiraglons within the last five years? Provide » Ust of Countries/Regions Visited Country/Region (1) Country/Region (2) Country/Region (3) CCountry/Resion (4) Ccountry/Resion (5) Have you belonged to, contributed to, or worked for any professional, social, or chartoble organization? 1 you have any speciatzes sis or raining, such a8 trearms, explosives, nuclear, bologieal, or cemical experience? Have you ever serves inthe mittary? Have you ever serves in, been a member of, of been involved with a arorntary une vine unt, rebel group, suerte group, or Security and Background Information (be you nave a communicable disease of public healt significance? (Communicable diseases of publ signfcance include hnpesicnae state goviGenNIVicommorxntalicetion aspx?a82U:¥6H 9M TNO%K2b2\e Vpb¥s2E4abaWVWVTZMEiakuXKUVSA%IG Consular Electronic Applicaton Center - Prin Application MARINE ENGINEER OFFICER ON FOREIGN GOING MERCHANT SHIPS, ‘OPERATION AND MAINTENANCE OF MARINE HACHINESY IN [XCCORDANCE WITH ALL INTERNTIONAL AND LOCAL REGULATIONS ‘AND COMPANY POLICIES. PARK momar INDIA 02261324600 MARINE ENGINEER OFFICER o Nor KNOW 0 Nor KNOW 24 DUNE 2016 20 JANUARY 2017, MARINE ENGINEER OFFICER ON FOREIGN GOING MERCHANT SHIPS, ‘OPERATION AND MAINTENANCE OF MARINE MACHINERY IN [ACCORDANCE WITH ALL INTERNRTIONAL AND LOCAL REGULATIONS ‘AND COMPANY POLICIES, ves [AMET UNIVERSITY 135, EAST COAST ROAD KANATHUR CCHENNAT ‘TAMIL NADU 0312 Noa BACHELOR OF ENGINEERING IN MARINE TECHNOLOGY ENGLISH HuNoL marara ves [UNITED STATES OF AMERICA malaysia AUSTRALIA UNITED KINGDOM cra No No No No Noana017 Consular Electronic Applicaton Center - Prin Application chancrol, gonorrhea, granuloma inguinal, infectious leprosy lymphogranuloma venereum, infectious stage syphilis, active {Uberculosis, and atners diseases as determined by the Department of Health and Human Services.) ‘De you nave @ mental or physical dlsorder that poses or is Ikaly to pose a threat tothe safety or welfare of yourself or others? ‘re you or have you ever been a drug abuser or addict? Have you ever been arrestee or conwicted for any offense or crme, even though subject of a pardon, amnesty, or other similar Have you ever violated, or engaged ina conspiracy to violate, any law relating to controlled substances? ‘Are you coming to the United States to engage in prostiution or unlawful commercialized vice or have you been engaged in prostation oF procuring prosctutes winin he past 10 years? Have you ever been invelved in, or do you seek to engage in, money laundering? Have you ever commited or conspired to commit a human trafficking offense in the Untee States or outside the United States? ‘re you the spouse, son, or daughter ofan individual who has commited of conspired to commit 8 human trafficking offense in the United States or outside te United States and have You within he lost Fve years, knowlnly benefied fram the Waficking peewee? Have you knowingly aldee, aborted, assisted or colluded witn an individual who has committe or conspired to commit a severe human vatficking offense inthe United States or outside the United States? you seek to engage in espionage, sabotage, export control ications, or any other llega activity while Inthe United States? 'e you seek to engage In terorist activities while In the United States or have you ever engaged in terrorist activities? Have you ever or do you intend ta provide fnancial assistance or other support te terrorists or terrorist organizations? ‘Are you a member or representatve ofa terrorist organization? Have you ever ordered incited, committed, assisted, or otherwise partcipated in genocide? Have you ever commited, ordered, incited, assisted, or otherwise participated in torture? Have you committee, ordered, incited, exssted, or otheraise participated in exrajuieia lings, political kings, or ether acts of Vience? Have you ever engaged in the recruitment or the use ofthe chile solciers? Have you, while serving as a government official, been responsible for or directly caried out, at anytime, particularly severe Vioatons of relgious freedom? Have you ever been srecty involved in the estabshment or enforcement ofthe population controls forcing @ woman to underge fn abortion against her free choice or 2 man ora woman to undergo steriization against his or ner fee wil Have you ever been directly involved in the coercve transolantaton of human organs or body tissue? Have you ever been the subject of @ 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 Unites States Immigration Bene by Troud or wilful misrepresentaton or other unlawful means? Have you fled to attend a hearing on removabity or inadmisiilty within the last five years? Have you ever been unlbtully present, overstayed the emount of time granted by an immigration officiel or otherwise violated the terms of U.S. usa? Have you ever withheld custody of @ U.S. eizen chil outside the United States from # person granted legal custody by 8 US. court Have you voted inthe United States in violation of any law or regulation? Have you ever renounced United States ciizenship for the purpose of avading taxation? Have you attended a public elementary school on student (F status ora public secondary schoo! after November 30, 1996 without reimbursing tre schoo? Crew Visa Information Specie job te aboard alrrat or vessel 2ND ENGINEER [Name of company that owns the aircraft or vessel you willbe working ANGLO EASTERN SHIP MGMT 1 PVT LTO, Company telephone number: 102261224600 id you acquire your position using @reeruting/manning/erewing No agency? Are you serving aboard a seagoing shi or vessel? ves Seageing Ship/Vessel Name: vy ucrimaTe Seagoing Ship/Vessel réentifeation Number: 9302665 Location Information Location where you will be submiting your application Current Location MUMBAI, INDIA Preparer of Application id anyone assist you in fling out this application? No hnpesienae state goviGenNIVicommorxntaglication aspxa82U:¥6H 9M TNO%K2b2Ie Vpb¥E4abaWWVTZMEiqkuXKUVSA%I6 No No No No No No No No No No No No No No No No No No No No No No No No No No No Noana017 Consular Electronic Applicaton Center - Prin Application Your Personal Copy -: Do Not Bring to Interview ‘You electronically signed your application on 24-Apr-2017 04:10:25 (GMT-05:00). You were required to elecronicaly sgn your application yourse Unless ozierwise exempt by regulation, even If the apaltatlon was prepared by Someone ether tan yoursel. Your lectontc signature eeries that ‘you have read and understood the questions In this application and that your answers are ue and correct tothe best of your knowledge and bale. ‘The submission ot an appleaton contaning any false or misleading statements may fesul inthe permanent refusal cfa visa or the defial cf ety int {he Untas States. All declarations made inthis application are unsworn declarations made under penalty of parry. (28 U.S.C. 1746). ‘You certified that you understand that you are required to submit your visa to the United States Immigration Oficer at the port where you apply to “nter the United States ord that possession of the visa does nak entile you to enter te United States pon Your arrival, You sre found to be inadmissible under U.S, immigration laws, You certifed that you understand tnt any wily false or misleading statement or wilful concealment of ‘Material fact made by you mithin tre appiteation may subject you to permanent exclusion from the Une States and, you ave admtes to the Unites States, may subject you ts cxminal prosecution anc/or deportation ‘The Information that you have provided in your application and other information submitee with your application may be accessible to other government agencies naving statutory or ether lawful authority to use such information, including fr law enforcement and immigration law Enforcement purposes. if ingerpints are collected 8s part of your appliston pracess, Sey may be used fr the purpose of comparing them to other {ingerorints inthe PO's Next Generation ientcation (NGT) fingerprint system or its successor systems (Including Wil erfminal, an latent hrigerp reposttares) The photograph tat you provice with your application may be used for employment verifeaion or ether U.S. law purposes hnpesienae state goviGenNIVicommorxntaglication aspxa82U:¥6H 9M TNO%K2b2Ie Vpb¥E4abaWWVTZMEiqkuXKUVSA%I6 6