U.S.

Department of State Approved OMB 1405-0134

Expires 07/31/2021
SUPPLEMENTAL SIV CHIEF OF MISSION APPLICATION Estimated Burden 1 Hour*

PLEASE TYPE OR PRINT YOUR ANSWERS IN THE SPACE PROVIDED BELOW EACH ITEM
PLEASE ATTACH AN ADDITIONAL SHEET IF YOU NEED MORE SPACE TO CONTINUE YOUR ANSWERS
1. Last Name(s) (List all spellings) 2. First Name(s) (List all spellings) 3. Full Name (In native alphabet)
Hayatullah Yawari
4. Clan or Tribe Name (If applicable) 5. All other names/aliases (If applicable)
Afghanistan Tajik NA
6. Date of Birth (mm-dd-yyyy) 7. Place of Birth (City, State/Province, Country)
09 September 1987 Khowaja Hejran district of Baghlan province, Afghanistan
8. Passport Number 9. National Identity Number (Tazkera)
NA 1398-0700-38724 (472273)
10. Sex 11. Spouse's Full Name (If married)
✘ Male Female Abedah Yawari
12. Father's Full Name 13. Mother's Full Name
Adena Mohammad Bibi Khurshid
14. Email Address and Phone Number
hayatullah.yawari1987@gmail.com
15. List names and dates of birth for your children (currently under age 21)
Raihan 17 May 2012, Tazkira # 1398-0700-38734, Mehran 10 Oct 2013 Tazkira # 1398-0700-38738, Ataullah 30 Sep 2017 Tazkira #
1398-0700-38742
16. List all countries you have entered in the last ten years. 17. List all countries that have ever issued you a passport. 18. Have you ever lost a
(Give the year of each visit) passport or had one stolen?

None None
Yes ✘ No

19. List your last five employers, including your current employer.
Company or Employer Work Location Supervisor's Email Dates of Employment Reason for
Job Title Supervisor's Name (mm-dd-yyyy) or "Present" Separation
Name (base or city/province) Address From To (If no longer employed)

119 Police Call 119 Call Center

MoI GIZ, UN Center Balkh Head
Head of Balkh HQ 2019 2021 Gov Collaps
119 Police Call Center 119 Call Center Mustafa Noristani, Head of People Police promotion to Balkh
MoI GIZ,UN Kabul Rahim Burhani
2018 2019

MoI CID CTD PD9, Center of CTD PD 9 CID, KBL HQ Salim Ehsas, Salim Kabul HQ CID 2010 2018 Transfer to People
CID Almas Police

20. Have you ever applied for Chief of Mission Approval? Yes ✘ No
If YES, please provide the case number(s) of the application(s).

I understand all the information I have provided in, or in support of, this application may be provided to other U.S. government agencies authorized to use such information for purposes
including enforcement of the laws of the United States. I understand all of the information contained in this form and I certify under penalty of perjury under the laws of the United States
of America that the foregoing is complete, true, and correct. I understand that any willfully false or misleading statement or willful concealment of a material fact made by me herein may
result in refusal of the visa, denial of admission to the United States, and, may subject me to criminal prosecution and/or removal from the United States.
Applicant's Signature Date (mm-dd-yyyy)

09-25-2021
CONFIDENTIALITY AND PAPERWORK REDUCTION ACT STATEMENTS
Confidentiality Statement - INA Section 222(f) provides that visa issuance and refusal records shall be considered confidential and shall be used only for the formulation, amendment, administration, or
enforcement of the immigration, nationality, and other laws of the United States. Certified copies of visa records may be made available to a court which certifies that the information contained in such records is
needed in a case pending before the court.
Paperwork Reduction Act Statement - Public reporting burden for this collection of information is estimated to average 1 hour per response, including time required for searching existing data sources,
gathering the necessary data, providing the information required, and reviewing the final collection. You do not have to provide the information unless this collection displays a currently valid OMB number. Send
comments on the accuracy of this estimate of the burden and recommendations for reducing it to: U.S. Department of State, A/GIS/DIR, Washington, DC 20520.

DS-157
10-2017