30.03.2017 Consular Electronic Application Center ­ Print Application Online Nonimmigrant Visa Application (DS­160) Application ­ Sensitive But Unclassified(SBU) We do not need a printed copy of your application at any point during your interview process. Only print this application if you want a copy for your own records. If you print your application, please keep it secure. Photo Provided: юonfirmation Numberх Your Personal Copy ­­ Do Not Bring to Interview Personal, Address, Phone, and Passport/Travel Document Information Name Providedх KIMз ьLIYь Full Name in Native Languageх Other Names Usedх NO Telecode Name Usedх NO Sexх FEMьLE Marital Statusх SINGLE яate of эirthх лп MьRюH мффл Place of эirthх ьKTOэEз ьKTOэE REGIONз KьZьKHSTьN юountryкRegion of Origin гNationalityдх KьZьKHSTьN яo you hold or have you held any nationality other than the one indicated above on nationality? NO ьre you a permanent resident of a countryкregion other than your countryкregion of origin гnationalityд above? NO National Identification Numberх фллолппрлттт UйSй Social Security Numberх яOES NOT ьPPLY UйSй Taxpayer Iя Numberх яOES NOT ьPPLY Home ьddressх уу ьPьRTйз мм HOUSEз ьKMESHIT STRйз YESSIL яISTRIюT юityх ьSTьNь StateкProvinceх ьKMOLь Postal ZoneкZIP юodeх лмлллл юountryкRegionх KьZьKHSTьN Same Mailing ьddress? YES Primary Phone Numberх утлмпррптуф Secondary Phone Numberх мсмфоуффнлн Work Phone Numberх яOES NOT ьPPLY Email ьddressх alika_kimыmailйru PassportкTravel яocument Typeх REGULьR PassportкTravel яocument Numberх Nрфлпсмр Passport эook Numberх яOES NOT ьPPLY юountryкьuthority that Issued PassportкTravel яocumentх KьZьKHSTьN юity Where Issuedх ьKTOэE StateкProvince Where Issuedх ьKTOэE REGION юountryкRegion Where Issuedх KьZьKHSTьN Issuance яateх мл JULY нллу Expiration яateх лф JULY нлму Have you ever lost a passport or had one stolen? NO https://ceac.state.gov/GenNIV/common/printapplication.aspx?gMCkew7DjJndrlnZ%2bmg7WZC7jDTg9dWbHFqb%2fS5Av6Q%3d 1/4 30.03.2017 Travel Information Consular Electronic Application Center ­ Print Application Your Personal Copy ­­ Do Not Bring to Interview The List of Purposes of Trip to the UйSй Purpose of Trip to the UйSй гмдх ьюьяEMIю OR LьNGUьGE STUяENT гFд Specifyх STUяENT гFмд Intended яate of ьrrivalх но ьPRIL нлмт Intended Length of Stay in UйSйх н YEьRгSд ьddress where you will stay in the UйSйх мнос ьZUSь STREET юityз Stateз PostalкZip юodeх SьN яIEGOз юьLIFORNIь фнммл PersonкEntity Paying for Your Tripх OTHER PERSON Person Paying for Your Tripх KIM з KULYьSH Telephone Numberх утлмрмсмофр Email ьddressх kulaфыmailйru Relationship to Youх PьRENT Is the address of the party paying for your trip the same as your Home or Mailing ьddress? NO Payerвs ьddressх тт KйOSPьNOVь STRй юityх ьKTOэE StateкProvinceх ьKTOэE REGION Postal ZoneкZIP юodeх лоллмн юountryкRegionх KьZьKHSTьN ьre there other persons traveling with you? NO Have you ever been in the UйSй? YES яate ьrrived гмдх нф NOVEMэER нлмс Length of Stayх п MONTHгSд яo you or did you hold a UйSй яriverвs License? NO Have you ever been issued a UйSй Visa? YES яate Last Visa was Issuedх му OюTOэER нлмс Visa Numberх Lпфлсрмс ьre you applying for the same type of visa? YES ьre you applying in the same country where the visa above is issued and is this country your principal country of residence? YES Have you been tenиprinted? YES Has your UйSй Visa ever been lost or stolen? NO Has your UйSй Visa ever been cancelled or revoked? NO Have you ever been refused a UйSй Visaз or been refused admission to the United Statesз or withdrawn your application for admission at the port of entry? NO Has anyone ever filed an immigrant petition on your behalf with the United States юitizenship and Immigration Services? NO U.S. Contact Information юontact Person Name in the UйSйх NьVьRROз KIYONNь Organization Name in the UйSйх SOUTHERN STьTES UNIVERSITY Relationship to Youх SюHOOL OFFIюIьL UйSй юontact ьddressх мтнф рTH ьVENUE SьN яIEGOз юьLIFORNIь фнмлм Phone Numberх мсмфнфумунф Email ьddressх infoыssuйedu Family Information Fatherвs Surnamesх KIM Fatherвs Given Namesх TьRьS Fatherвs яate of эirthх лн ьUGUST мфсл Is your father in the UйSй? NO Motherвs Surnamesх KIM Motherвs Given Namesх KULYьSH Motherвs яate of эirthх мо SEPTEMэER мфсо Is your mother in the UйSй? NO яo you have any immediate relativesз not including parents in the UйSй? NO яo you have any other relatives in the United States? NO https://ceac.state.gov/GenNIV/common/printapplication.aspx?gMCkew7DjJndrlnZ%2bmg7WZC7jDTg9dWbHFqb%2fS5Av6Q%3d 2/4 30.03.2017 Consular Electronic Application Center ­ Print Application Work/Education/Training Information Primary Occupationх Your Personal Copy ­­ Do Not Bring to Interview STUяENT Present Employer or School Nameх SOUTHERN STьTES UNIVERSITY ьddressх мтнф рTH ьVENUE юityх SьN яIEGO StateкProvinceх юьLIFORNIь Postal ZoneкZip юodeх фнмлм юountryкRegionх KьZьKHSTьN Work Phone Numberх смфнфумунф Monthly Salary in Local юurrency гif employedдх яOES NOT ьPPLY эriefly яescribe your яutiesх STUяYING эUSINESS ьяMINISTRьTIONз MьNьGEMENT ьNя OPERьTIONS гMэьд Were you previously employed? YES Employer Name гмдх IT ENGINEERING Sь Employer ьddressх ф эEIэITSHILIK STRйз SьRYьRKь яISTRIюT юityх ьSTьNь StateкProvinceх ьKMOLь Postal ZoneкZip юodeх лмлллл юountryкRegionх KьZьKHSTьN Telephone Numberх утмтнтротнп Job Titleх TURKISH TRьNSLьTOR Supervisorвs Surnameх TURSYNэEKOVь Supervisorвs Given Nameх ZHULяYZ Employment яate Fromх нл SEPTEMэER нлмп Employment яate Toх нн NOVEMэER нлмс эriefly describe your dutiesх TRьNSLьTION OF юONTRUюTION яOюUMENTьTIONS Security and Background Information яo you have a communicable disease of public health significance? гюommunicable diseases of public significance include chancroidз gonorrheaз granuloma inguinaleз infectious leprosyз lymphogranuloma venereumз infectious stage syphilisз active tuberculosisз and others diseases as determined by the яepartment of Health and Human Servicesйд NO яo 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? NO ьre you or have you ever been a drug abuser or addict? NO Have you ever been arrested or convicted for any offense or crimeз even though subject of a pardonз amnestyз or other similar action? NO Have you ever violatedз or engaged in a conspiracy to violateз any law relating to controlled substances? NO ьre 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 мл years? NO Have you ever been involved inз or do you seek to engage inз money laundering? NO Have you ever committed or conspired to commit a human trafficking offense in the United States or outside the United States? NO ьre you the spouseз sonз 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 last five yearsз knowingly benefited from the trafficking activities? NO Have you knowingly aidedз abettedз 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 United States? NO яo you seek to engage in espionageз sabotageз export control violationsз or any other illegal activity while in the United States? NO яo you seek to engage in terrorist activities while in the United States or have you ever engaged in terrorist activities? NO Have you ever or do you intend to provide financial assistance or other support to terrorists or terrorist organizations? NO ьre you a member or representative of a terrorist organization? NO Have you ever orderedз incitedз committedз assistedз or otherwise participated in genocide? NO Have you ever committedз orderedз incitedз assistedз or otherwise participated in torture? NO Have you committedз orderedз incitedз assistedз or otherwise participated in extrajudicial killingsз political killingsз or other acts of violence? NO Have you ever engaged in the recruitment or the use of the child soldiers? NO Have youз while serving as a government officialз been responsible for or directly carried outз at any timeз particularly severe violations of religious freedom? NO 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 undergo sterilization against his or her free will? NO Have you ever been directly involved in the coercive transplantation of human organs or bodily tissue? NO Have you ever been the subject of a removal or deportation hearing? NO Have you ever sought to obtain or assist others to obtain a visaз entry into the United Statesз or any other United States immigration benefit by fraud or willful misrepresentation or other unlawful means? NO https://ceac.state.gov/GenNIV/common/printapplication.aspx?gMCkew7DjJndrlnZ%2bmg7WZC7jDTg9dWbHFqb%2fS5Av6Q%3d 3/4 30.03.2017 Consular Electronic Application Center ­ Print Application Have you failed to attend a hearing on removability or inadmissibility within the last five years? NO Your Personal Copy ­­ Do Not Bring to Interview Have you ever been unlawfully presentз overstayed the amount of time granted by an immigration official or otherwise violated the NO Have you ever withheld custody of a UйSй citizen child outside the United States from a person granted legal custody by a UйSй court? NO Have you voted in the United States in violation of any law or regulation? NO terms of a UйSй visa? Have you ever renounced United States citizenship for the purpose of avoiding taxation? NO Have you attended a public elementary school on student гFд status or a public secondary school after November олз мффс without reimbursing the school? NO Student/Exchange Visa Information ьdditional Point of юontact Informationх Name гмдх IэRьYEVьз ьIGERIM Street ьddressх нE ZHUэьNOVь STRй юityх ьKTOэE StateкProvinceх ьKTOэE REGION Postal ZoneкZIP юodeх лолллл юountryкRegionх KьZьKHSTьN Telephone Numberх уттуроорррт Email ьddressх angelиaiыmailйru Name гндх YESKьLIYEVьз GULSьYь Street ьddressх нл ьPьRTйз у RESPUэLIюь ьVENUE ьLMьTY яISTRIюT юityх ьSTьNь StateкProvinceх ьKMOLь Postal ZoneкZIP юodeх лмлллл юountryкRegionх KьZьKHSTьN Telephone Numberх утлмлттонмф Email ьddressх gulsayaфмыgmailйcom SEVIS Iях Nллннлорруф Name of Schoolх SOUTHERN STьTES UNIVERSITY юourse of Studyх MьSTER OF эUSINESS ьяMINISTRьTION Street ьddressх мтнф рTH ьVENUE SьN яIEGOз юьLIFORNIь фнмлм Location Information Location where you will be submitting your application юurrent Locationх ьSTьNьз KьZьKHSTьN Preparer of Application яid anyone assist you in filling out this application? NO Your Personal Copy ­­ Do Not Bring to Interview г з олиMarинлмт лпхпохоу гGMTилрхллдй дз з з з з з з Ф з Ш й й гну UйSйю мтпсд з г Ш й з з и й й з йЕ з https://ceac.state.gov/GenNIV/common/printapplication.aspx?gMCkew7DjJndrlnZ%2bmg7WZC7jDTg9dWbHFqb%2fS5Av6Q%3d з Ф дй 4/4
