U.S.

Department of State Approved OMB 1405-0018

Expires 11/30/2010
NONIMMIGRANT VISA APPLICATION Estimated Burden 1 Hour
See Page 2

PLEASE TYPE OR PRINT YOUR ANSWERS IN THE SPACE PROVIDED BELOW EACH ITEM 11-Aug-2008
1. Passport Number 2. Place of Issuance : DO NOT WRITE IN THIS SPACE
City Country State/Province B-1/B-2 MAX B-1 MAX B-2 MAX
AHMEDABAD INDIA GUJARAT Other _______________________ MAX
F6269906 Visa Classification
3. Issuing Country 4. Issuance Date (dd-mmm-yyyy) 5. Expiration Date (dd-mmm-yyyy) Mult or _____________________________
INDIA Number of Applications
15-Feb-2006 14-Feb-2016
Months ____________________________
6. Surnames (As in Passport) Validity
GAJJAR Issued/Refused

7. First and Middle Names (As in Passport)

On ________________ By _____________
Under SEC. 214(b) 221(g)
JIGAR NARESHKUMAR
8. Other Surnames Used (Maiden, Religious, Professional, Aliases)
NA Other _________________________ INA
Reviewed By ________________________

9. Other First and Middle Names Used 10.Date of Birth(dd-mmm-yyyy)

NA
15-Oct-1983

11. Place of Birth : 12. Nationality

City Country State/Province
INDIA GUJARAT INDIA
AHMEDABAD

13. Sex 14. National Identification Number 15. Home Address (Include apartment number, street, city, state or province, postal zone and country)
Male (If Applicable) B8 NAVRATNA APPARTMENT,
Female CTMC ROSS ROAD,
NA
AHMEDABAD, 380026, GUJARAT, INDIA
16. Home Telephone Number Business Phone Number Mobile/Cell
91-079-25857212 91-02764-264736 9909032996
Fax Number Fax Number Business Pager Number

17. Marital Status 18. Spouse's Full Name (Even if divorced or separated. Include maiden name.) 19. Spouse's DOB (dd-mmm-yyyy)
Married Single (Never Married) NA
Widower Seperated Divorced

20. Name and Address of Present Employer or School Address: BEHIND GEB,
Name: RE ROLLING MILL COMPOUND,
GAJANAND ENGINEERING WORKS KADI, GUJARAT, INDIA, 382715
21. Present Occupation ( If retired, write "retired" 22. When Do You Intend To Arrive In The U.S.? 23.E-Mail Address
If student,write "student".)
(Provide Specific Date if Known)
TRAINEE ENGINEEER [email protected]
10-Sep-2008
24. At What Address Will You Stay in The U.S.?
4701,
,LIMESTONE ROAD,
WILMINGTON, DELAWARE, 19808
25. Name and Telephone Numbers of Person in U.S. Who You Will be Staying With or
Visiting for Tourism or Business
Name Home Phone
9001961133
LARRY EBY DO NOT WRITE IN THIS SPACE
Business Phone Cell Phone

302-2256289

26. How Long Do You Intend 27. What is The Purpose of Your Trip?
To Stay in the U.S.?
FOR STUDY OF MASTER OF MANAGEMENT 50 mm x 50 mm
2 YEAR(S)

PHOTO

28. Who Will Pay For Your Trip? 29. Have You Ever Been in The U.S? Yes No
FATHER Staple or glue photo here

WHEN?

FOR HOW LONG?

DS-156 Page 1 of 2
02-2003
PREVIOUS EDITIONS OBSOLETE
30. Have You Ever Been Issued a U.S. Visa? Yes No 31. Have You Ever Been Refused a U.S. Visa? Yes No
WHEN? 30-Jul-2008 WHEN? 30-Jul-2008
WHERE? MUMBAI WHERE? MUMBAI
F-1
WHAT TYPE OF VISA? F-1 WHAT TYPE OF VISA?

32. Do You Intend To Work in The U.S.? (If YES, give Yes No 33. Do You Intend to Study in The U.S.? (If YES, give Yes No
the name and complete address of U.S employer.) the name and complete address of the school.)
GOLDEY BEACOM COLLEGE,4701,LIMESTONE
ROAD,WILMINGTON,DELAWARE-19808
34. Names and Relationships of Persons Traveling With You NA

35 .Has Your U.S. Visa Ever Been Cancelled or Revoked? 36. Has Anyone Ever Filed an Immigrant Visa Petiton on Your Behalf ?
Yes No Yes No If yes,Who?

37. Are Any of The Following Persons in The U.S., or Do They Have U.S. Legal Permanent Residence or U.S. Citizenship?
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.).

Yes No Husband/ Yes No Fiance / Yes No

Wife Fiancee
Father / Brother /
Yes No Yes No Son /
Mother Daughter Sister
38. IMPORTANT: ALL APPLICANTS MUST READ AND CHECK THE APPROPRIATE BOX FOR EACH ITEM. A visa may not be issued to persons
who are within specific categories defined by law as inadmissible to the United States (except when a waiver is obtained in advance). Is any of the
following applicable to you?
• Have you ever been arrested or convicted for any offense or crime, even though subject of a pardon, amnesty or other
Yes No
similar legal action? Have you ever unlawfully distributed or sold a controlled substance (drug), or been a prostitute or
procurer for prostitutes?
• Have you ever been refused admission to the U.S., or been the subject of a deportation hearing, or sought to obtain or
Yes No
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?
• Do you seek to enter the United States to engage in export control violations, subversive or terrorist activities, or any Yes No
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?
• Have you ever violated the terms of a U.S. visa, or been unlawfully present in, or deported from, the United States? Yes No
• 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 Yes No
court, voted in the United States in violation of any law or regulation, or renounced U.S. citizenship for the
purpose of avoiding taxation?
• Have you ever been afflicted with a communicable disease of public health significance or a dangerous physical or
Yes No
mental disorder, or ever been a drug abuser or addict?

While a YES answer does not automatically signify ineligibility for a visa, if you answered YES you may be required to personally appear before a
consular officer.

39. Was this Application Prepared by Another Person on Your Behalf?

Yes No
(If answer is YES, then have that person complete item 40.)
40. Application Prepared By :
NAME : Relationship to Applicant :

ADDRESS :

Signature of Person Preparing Form : ________________________________________________________ DATE (dd-mmm-yyyy)

41. 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.

APPLICANT'S SIGNATURE ___________________________________________________________ DATE (dd-mmm-yyyy) 04-Aug-2008

Privacy Act and Paperwork Reduction Act Statements

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 the 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.

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/RPS/DIR, Washington , D.C. 20520.

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