1119726, 552 PM Consular Electronic Application Contor- Print Application es, US. pean st Ns 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 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: Photowill be taken at the ASC. Confirmation Number: Your Personal Copy - Do Not Bring to Interview Personal, Address, Phone, and Passport/Travel Document Information Name Provided: Full Name in Native Language: Other Names Used! Telecode Name Use¢ Sex Marital Status Date of Birth: Place of Birth Country/Region of Origin (Nationality) Do you hold or have you held any nationality ether than the one indicated above on nationality? ‘Are you a permanent resident of a country/region other than your Country/region of origin (nationality) above? National Identification Number: U.S. Social Security Number U.S. Taxpayer 1D Number: Home Address: ory: ‘State/Province: Postal Zone/ZIP Code: Country/Region: ‘Same Malling Address? Your Personal Copy - NAGULAPALLY, RAJESHWA, DOES NOT APPLY No No MALE MARRIED 12 AususT 1977 VANNEL, TELANGANA, INDIA INDIA No No DOES NOT APPLY DOES NOT APPLY DOES NOT APPLY 7-45 BY 4 VANNELS, ‘TELANGANA, DOES NOT APPLY INDIA Yes Do Not Bring to Interview bitpsficeacstate,gov/GenIVicommoniprintapplication.aspx?FatmyZ%Zbqb9ViK%2MAsq7LT%ZbLKA4NUoGTISEKyEWhsOag%éd 181119126, 5:52 PM Your Personal Copy Primary Phone Number: Secondary Phone Number Work Phone Number: Do you have any adctional phone numbers? mall Address Do you have any adctional email addresses? Do you have 8 social mecia presence? Social Media Patfrm: (1) Social Media Identifier: Do you have any additional socal media presence? Passport/Travel Document Type: Passport/Travel Document Number: Passport Book Number: Country/Authorty that Issued Passport/Travel Document: City Where Issued State/Province Where Issued Country/Region Where Issued: Issuance Date: expiration Date: Have you ever lo passport or had one stolen? Travel Information The List of Purposes of Trp to the U.S, Purpose of Trp to the U.S. (1): Specity: Have you made specific travel plans? Intended Date of Arrival: Intended Length of Stay in U.S. Address where you will stay in the U.S, City, State, Postal/Zip Code: PersonyEntity Paying for Your Trp: ‘Are there other persons traveling with you? ‘Are you traveling as part of a group or organization? Persons Traveling with You Name (1) Relationship to You: Have you ever been in the U.S.? Have you ever been issued a U.S. visa? Have you ever been refused a U.S. Visa, or been refused admission to the United States, or withdrawn your application for admission at the port of entry? Has anyone ever filed an immigrant petition on your behalf with the United States Citizenship and Immigration Services? U.S. Contact Information Contact Person Name in the U.S. Organization Name in the U.S. Your Personal Copy Consular Electronic Application Center - Print Application - Do Not Bring to Interview 7971608903 DOES NOT APPLY DOES NOT APPLY No [email protected] No NONE No REGULAR 3365279 DOES NOT APPLY INDIA HYDERABAD TELANGANA INDIA 12.ULy 2018 11 aULy 2028 No ‘TEMP, BUSINESS PLEASURE VISITOR (8) BUSINESS & TOURISM (TEMPORARY VISITOR) (e1/82) No (03 APRIL 2024 3 MONTH(S) 16543 GEORGIA OAK RO CHARLOTTE, NORTH CAROLINA 28269 SELF ves No NAGULAPALLY, HEMALATHA SPOUSE No No No No NAGULAPALLY, SARITA, AMERICAN EXPRESS - Do Not Bring to Interview bitpsficeacstate,gov/GenIVicommoniprintapplication.aspx?FatmyZ%Zbqb9ViK%2MAsq7LT%ZbLKA4NUoGTISEKyEWhsOag%éd 251119126, 5:52 PM Consular Electronic Application Center - Print Application Your Personal Copy -- Do Not Bring to Interview Relationship to You: RELATIVE U.S. Contact Address: (6543 GEORGIA OAK RO CHARLOTTE, NORTH CAROLINA 28269 Phone Numbe 4961608915, Email Address: DOES NOT APPLY Informati Father's Surnames: NADIE Father's Given Names: DEVANNA Father's Date of Birth 20 NOT KNOW 1s your father in the U.S.? No Mother's Sumames NAGULAPALLY Mother's Given Names: DEVAL Mother's Date of Birth D0 NOT KNOW Is your mother in the U.S.? No Do you have any immediate relatives, not including parents in the U.S.? YES Relative Name (1) NAGULAPALLY, SARITHA Relationship to you: cm Status NONIMMIGRANT ‘Spouse's Full Name: NAGULAPALLY, HEMALATHA ‘Spouse's Date of Birth: 12 FEBRUARY 1983, ‘Spouse's Country/Region of Origin (Nationality) INDIA Spouse's City of Birth: VANNEL-S, Spouse's Country/Region of Birth: INDIA Spouse's Address: SAME AS HOME ADDRESS Work/Education/Training Information Primary Occupation NOT EMPLOYED Explain: OWN LANDS AND I ALSO DO POUL “TRY FARMING ‘Were you previously employed? No Mave you attended any educational institutions ata secondary level or NO Do you belong to @ clan or tribe? No Provide @ List of Languages You Speak Language Name (1): Tewusu Have you traveled to any countries/regions within the last five years? NO Have you belonged to, contributed to, or worked for any professional, NO socal, oF charitable organization? Do you have any specialized skills or training, such as firearms, No explosives, nuclear, biological, or chemical experience? Have you ever served in the military? No Have you ever served in, been a member of, or been involved with @ NO paramilitary unit, vigilante unit, rebel group, guerrilla group, or Insurgent organization? Security and Background Information Do you have @ communicable disease of public health significance? (Communicable diseases of public significance No include chancroid, gonormhea, granuloma inguinale, infectious leprosy, lymphogranuloma venereum, infectious stage syphils, active tuberculosis, and others diseases as determined by the Department of Health ang Human Services.) Your Personal Copy -- Do Not Bring to Interview bitpsficeacstate,gov/GenIVicommoniprintapplication.aspx?FatmyZ%Zbqb9ViK%2MAsq7LT%ZbLKA4NUoGTISEKyEWhsOag%éd 351119126, 5:52 PM Consular Electronic Application Center - Print Application Your Personal Copy -- Do Not Bring to Interview Do you have a mental ar physical disorder that poses or is likely to pose a threat to the safety or welfare of yourself or others? ‘Are you oF have you ever been a drug abuser or addict? Have you ever been arrested ar convicted for any offense or crime, even though subject of a pardon, amnesty, or ‘other Similar action? Have you ever violated, or engaged in @ conspiracy to violate, any law relating to controlled substances? [Are you coming to the United States to engage in prostitution or unlawful commercialized vice or have you been ‘engaged in prostitution ar procuring prostitutes within the past 10 years? Have you ever been involved in, ar do you seek to engage In, money laundering? Have you ever committed or conspired to commit @ human trafficking offense in the United States or outside the United States? [Are you the spouse, son, 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 years, knowingly benefited from the trafficking activities? Have you knowingly aided, abetted, 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? Do you seek to engage in espionage, sebotage, export control violations, or any other illegal activity while in the United States? Do you seek to engage in terrorist activities while in the United States or have you ever engaged in terrorist activities? Have you ever or do you intend to provide financial asistance or other support to terrorists or terrorist organizations? ‘Are you @ member or representative of a terrorist organization? {Are you the spouse, son, or daughter of an individual who has engaged in terrorist activity, including providing financial assistance or other support to terrorists or terrorist organizations, in the last ve years? Have you ever ordered, incited, committed, assisted, or otherwise participated in genocide? Have you ever committed, ordered, incited, assisted, or otherwise participated in torture? Have you committed, ordered, incited, assisted, or otherwise participated in extrajudicial killings, polit fof other acts of violence? killings, Have you ever engaged in the recruitment or the use of the child soldiers? Have you, while serving as a government official, been responsible for or directly carried out, particularly severe violations of religious freedom? ny time, Have you ever been directly involved in the establishment or enforcement of the population controls forcing a woman to underge an abortion against her free choice or a man or a woman to undergo sterilization against his or her free will? Have you ever been directly Involved In the coercive transplantation of human organs or bodily tissue? Have you ever sought to obtain or assist others to obtain a visa, entry into the United States, or any other United ‘States immigration benefit by fraud or willful misrepresentation or other unlawful means? Have you ever been removed or deported from any country? Have you ever withheld custody of a U.S. citizen child outside the United States from a person granted legal custody by a US. court? Have you voted in the United States In violation of any law or regulation? Have you ever renounced United States citizenship for the purpose of avoiding taxation? Location Information Location where you will be submitting your application Current Location HYDERABAD, INDIA Preparer of Application Did anyone assist you in filing out this application? ves Preparer Sumames: NAGULAPALLY Preparer Given Names: SARITHA Organization Name: ‘Street Address: AMERICAN EXPRESS 6543 GEORGIA OAK RD, CHARLOTTE, NC 28269 Your Personal Copy -- Do Not Bring to Interview bitpsficeacstate,gov/GenIVicommoniprintapplication.aspx?FatmyZ%Zbqb9ViK%2MAsq7LT%ZbLKA4NUoGTISEKyEWhsOag%éd 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 4651119126, 5:52 PM Consular Electronic Application Center - Print Application Your Personal Copy -- Do Not Bring to Interview cry: CHARLOTTE State/Province: NORTH CAROLINA Postal Zone/ZIP Code: DOES NOT APPLY Country/Region: UNITED STATES OF AMERICA Relationship to You: DAUGHTER, Your Personal Copy -- Do Not Bring to Interview You electronically signed your application on 19-Jan-2024 06:20:25 (GMT-05:00). You were required to electronically sign your application yourself, unless otherwise exempt by regulation, even if the application was preparec by someone other than yourself Your electronic signature certifies that you have read and understood the questions in this application and that your answers are true land correct to the best of your knowledge and belief. The submission of an application containing any false or misleading statements may result in the permanent refusal of a visa or the Genial of entry into the United States. All declarations made in this application are unsworn declarations made under penalty of perjury. (28 U.S.C, 1746), You certified that you understand that you are required to submit your visa to the United States Immigration Officer at the port where you apply to enter the United States, and that possession of the visa does not entitle you to enter the United States if, upon your arrival, you are found to be inadmissible under U.S. Immigration laws. You certified that you understand that any willfully false ‘or misleading statement or wilful concealment of @ material fact made by you within the application may subject you to permanent fcusion from the United States and, if you are admitted tothe United States, may subject yu to criminal presecution and/or jeportation, The information that you have provided in your application and other information submitted with your application may be accessible to other government agencies having statutory oF other lawful authority to Use such information, Including for law enforcement and immigration law enforcement purposes. If fingerprints are collected as part of your application process, they may be used far the Durpase of comparing them to other fingerprints in the FBI's Next Generation Identification (NGI) fingerprint system or its successor systems (including civil, criminal, and latent fingerprint repositories). The photograph that you provide with your apalication may be Used for employment verification or other U.S. law purposes. bitpsficeacstate,gov/GenIVicommoniprintapplication.aspx?FatmyZ%Zbqb9ViK%2MAsq7LT%ZbLKA4NUoGTISEKyEWhsOag%éd 55