◆护照号码
Passport Number

◆签发护照地点 Place of Issuance
城市 City 
国家 Country 
州∕省份 State/Province 

◆签发您护照的国家 Issuing Country 

◆签照日期（日/月/年）
Issuance Date (dd-mm-yyyy)
日 day | 月 month | 年 year 

◆失效日期（日/月/年）
Expiration Date (dd-mmh-yyyy)
日 day | 月 month | 年 year 

◆姓（如护照所显示）
Surnames (As in Passport)

◆名（如护照所显示）
First and Middle Names (As in Passport) 

◆其他姓氏（未婚时称呼/宗教称呼/工作用称呼/化名）－（没有请留空）
Other Surnames Used (Maiden, Religious, Professional, Aliases)

◆其他名字 －（没有请留空）
Other First and Middle Names Used

◆出生日期（日/月/年）
Date of Birth (dd-mm-yyyy)
日 day | 月 month | 年 year 

◆出生地 Place of Birth
州∕省份 State/Province
城市 City
国家 Country 

◆现国籍
Nationality

◆性别 Sex
男 Male
女 Female

◆身份证号码
National Identification Number

◆住址（国家 邮编区号 州∕省 城市 街道 单元号码）
Home Address (Include apartment number, street, city, state or province, postal zone and country)
街道名称1 
Street Address Line 1
街道名称2 
Street Address Line 1
城市 City
州/省份 State/Province
邮编区号 Postal Code
国家 Country 

◆联系方式 （没有请填NONE） Contact
住宅电话 Home Telephone Number
工作电话 Business Phone Number
移动电话 Mobile/Cell Number
传 真 Fax Number
工作传真号码 Business Fax Number
传呼机号码(BP 机) Pager Number

◆婚姻状况
Marital Status 

◆配偶姓名（离婚或分居，包括婚前姓氏）－（没有请留空）
Spouse's Full Name(Even if divorced or separated. Include maiden name.)

◆配偶出生日期（日/月/年）－（没有请留空）
Spouse's DOB (dd-mm-yyyy)
日 day | 月 month | 年 year 

◆现任僱主或就读学校名称和地址
Name and Address of Present Employer or School
名 称 Name 
地址 Address 

◆现任职业-若退休则输入"retired",学生则输入"student"
Present Occupation-(If retired, write & retired". If student, write "student".) 

◆拟抵美时间（日/月/年)-（请提供日期）
When Do You Intend To Arrive In The U.S.(Provide specific date if known)
日 day | 月 month | 年 year 

◆电子邮件地址
E-Mail Address

◆在美期间住址
At What Address Will You Stay in The U.S.
街道名称 Street Address Line 1
街道名称 Street Address Line 2
城市 City
省份/州 State/Province
邮遍区号 Postal Code

◆您将在美逗留∕旅游探访∕公干的联系人的姓名及电话号码 －（没有请填NONE）
Name and Telephone Numbers of Person in U.S. Who You Will Be Staying With or Visiting for Tourism or Business 
姓名 Name 
住宅电话 Home Phone
工作电话 Business Phone
移动电话 Cell Phone

◆拟在美逗留多久
How Long Do You Intend To Stay in The U.S.

◆此行目的
What is The Purpose of Your Trip 

◆此行费用由谁负担
Who Will Pay For Your Trip

◆您是否到过美国
Have You Ever Been to U.S.A 
有 Yes 没有 No
何时 When
日 day | 月 month | 年 year
逗留了多久 
FOR HOW LONG
其他赶美经历 
Enter Additional Visits to the U.S. Here 

◆您是否得到过美国的签证
Have You Ever Been Issued a U.S. Visa
得到过 Yes 没有得到过 No
何时 When
日 day | 月 month | 年 year
在何地获得 Where
签证类型 WHAT TYPE OF VISA
其他签证经历 Enter Additional Visa Issuances Here 

◆您是否有过被美国拒签的经历
Have You Ever Been Refused a U.S. Visa
有 Yes 没有 No
何时 When
日 day | 月 month | 年 year
在何地 Where
签证类型 WHAT TYPE OF VISA
其他被美国拒签经验 Enter Additional Visa Refusals Here 

◆您是否有意在美国就业
Do You Intend To Work in The U.S.
有意 Yes 无意 No
（如有意就业﹐请注明美国僱主的名称及地址）
(If YES, give the name and complete address of U.S. employer.)

◆您是否有意在美国就读
Do You Intend To Work in The U.S.
有意 Yes 无意 No
（如有意就读者﹐请注明美国学校的名称及地址）
(If YES, give the name and complete address of the school.) 

◆同行人姓名，与您的关系 （没有请填NONE）
Names and Relationships of Persons Traveling With You 

◆您的美国签证有否曾被吊销作废
Has Your U.S. Visa Ever Been Cancelled or Revoked 
有过 Yes 没有 No

◆是否曾有人为您申办过移民签证
Has Anyone Ever Filed an Immigrant Visa Petition on Your Behalf
有过 Yes 没有 No
If Yes, Who?
如“有”﹐是谁?

◆下列亲属中是否有人目前已在美国?他们是否是美国合法永久居民或美过公民?
Has Your U.S. Visa Ever Been Cancelled or Revoked?Are Any of The Following Persons in The U.S., or Do They Have U.S.Legal Permanent Residence or U.S. Citizenship?
请注明“在美国”/“不在美国”並证明其在美国的身份（即：是美国合法永久居民还是美过公民，是否正在美国访问/留學/工作等等）
Mark YES or NO and indicate that person's status in the U.S. (i.e., U.S. legal permanent resident, U.S. citizen,visiting, studying, working, etc.).

◆请注意﹕每位申请人都必須通读並回答下列所有问题
IMPORTANT: ALL APPLICANTS MUST READ AND CHECK THE APPROPRIATE BOX FOR EACH ITEM.
1. 是否由于犯有任何罪刑而曾经被逮捕和被判有罪，即时后来得到了宽恕、赦免或受益于其他类似措施？是否曾非法分发或出售过受控物品(毒品)？是否曾从事卖淫活动或曾为卖淫者拉客？
Have you ever been arrested or convicted for any offense or crime, even though subject of a pardon, amnesty or other similar legal action? Have you ever unlawfully distributed or sold a controlled substance(drug), or been aprostitute or procurer for prostitutes?
是 Yes 否 No

2. 是否曾经被美国拒绝入境或成为递解出境听证的对象？是否曾以欺骗或故意作假及其他手段歧途自己得到或帮助他人得到美国签证或任何其他移民福利、企图自己或帮助他人进入美国？是否曾在1996年11月30日以后以学生身份到美国公立小学或公立中学就读而未向学校补偿费用？
Have you ever been refused admission to the U.S., or been the subject of a deportation hearing or sought to obtain or assist others to obtain a visa, entry into the U.S., or any other U.S. immigration benefit by fraud or willful misrepresentation or other unlawful means? Have you attended a U.S. public elementary school on student (F) status or a public secondary school after November 30, 1996 without reimbursing the school?
是 Yes 否 No

可登陆www.XMvisa.com查看相关签证信息

3. 是否希望进入美国？是否为了违反出口控制的活动、为了从事颠覆或恐怖主义活动？是否有其他非法目的？是否是目前被美国国务卿认定的恐怖主义组织的成员或代表？是否曾参加过德国纳粹政府指使下进行的迫害？是否参加过旨在种族灭绝的屠杀？
Do you seek to enter the United States to engage in export control violations, subversive or terrorist activities, or any other unlawful purpose? Are you a member or representative of a terrorist organization as currently designated by the U.S. Secretary of State? Have you ever participated in persecutions directed by the Nazi government of Germany; or have you ever participated in genocide?
是 Yes 否 No

4. 是否曾违反过美国签证的有关规定？是否曾非法进入美国或者曾被美国递解出境？
Have you ever violated the terms of a U.S. visa, or been unlawfully present in, or deported from, the United States?
是 Yes 否 No

5. 是否曾拒绝把身为美国公民但身处美国境外的子女的监护权移交给美国法庭享有监护权的人？是否曾违反法规在美国投票或为达道逃避税务的目的而放弃美国国籍？
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, voted in the United States in violation of any law or regulation, or renounced U.S. citizenship for the purpose of avoiding taxation?
是 Yes 否 No

6. 是否曾感染对公共健康有影响的传染病或患过构成危险体质病变或精神病？是否曾滥用毒品或药物？是否用毒成瘾？
Have you ever been afflicted with a communicable disease of public health significance or a dangerous physical or mental disorder, or ever been a drug abuser or addict?
是 Yes 否 No

◆本人申请表是否由他人代为填写
Was this Application Prepared by Another Person on Your Behalf
有无代填人
有 Yes 没有 No

◆本申请表填写人
Application Prepared By
姓 名 NAME
与申请人关系 Relationship to Applicant 
地 址 ADDRESS
申请人签字 APPLICANT'S SIGNATURE ____________________________________________
日期（日/月/年） DATE (dd-mm-yyyy) __________________________________________

◆我特此确认﹐本申请表中所有问题本人均已通读领会﹐且本人在申请表上所做之回答就本人所知均属实无误。本人确知﹐任何谬误或误导之辞都可能导致本人永远被拒绝或永远不得进入美国。本人确知﹐签证持有人如被认定为不许入境者﹐则不得因持有签证而自动享受抵达入境口岸即可进入美国的权利。
I certify that I have read and understood all the questions set forth in this application and the answers I have furnished on this form are true and correct to the best of my knowledge and belief. I understand that any false or misleading statement may result in the permanent refusal of a visa or denial of entry into the United States. I understand that possession of a visa does not automatically entitle the bearer to enter the United States of America upon arrival at a port of entry if he or she is found inadmissible.
申请人签字 APPLICANT'S SIGNATURE ____________________________________________
日期（日/月/年） DATE (dd-mm-yyyy) __________________________________________