What is your full name, as shown in your current passport or travel document?*
Are you now or have you ever been known by another name?*
If yes, what is your other full name?
What is your complete current address?*
How long have you lived at this address?*
Passport no. or travel document no
Place of issue ( city or province)
Do you have another passport or travel document? If yes, provide passport no., place where issued, issue date and expiration date for all old / expired passports
If you hold another passport, the passport is for which country?
What permission do you have in Bermuda? (Check all that apply)
What is your employment status? (Check all that apply)
If employed, what is your employer's name (the company name)?
Employers address - town/ city , province / state / postal code/ country
Date you started working for this employer
How much do you earn each month after tax? Indicate currency
Do you have another income or any savings?
For other regular income - What kind of other regular income do you have?
For savings - How much money do you have in savings ? Indicate currency.
How much money are you planning to spend on your visit to the US?
What is the total amount of money you spend each month? ( for cost of living , money given to dependents, etc.)
Will anyone be paying towards the cost of your visit?
You must give your planned dates of travel o the US. This does not mean your visa will only be valid for these dates.
Date you will leave the US
What is the main reason for your visit to the US?
Give details of the main purpose of your visit and anything else you plan to do on your trip
Are there any other persons travelling with you?
Given name , family name of your spouse
Date of birth of your spouse
What is the Nationality of your spouse?
Do they currently live with you?
How many times have you visited Canada in the past 10 Years?
How many times have you visited New Zealand in the past 10 Years?
Have you ever been in the US?
How many times have you visited USA in the past 10 Years?
Have you ever been issued a US Visa?*
If Yes, Date Visa Issued:
If Yes, Date of visa expiration:
If Yes, What is your visa number?
Has your US visa ever been lost or stolen?
Has your US Visa ever been cancelled or revoked?
Has you ever been refused a US Visa, or been refused admission to the US?
Have you been ten printed?
How many times have you visited Schengen Ares in the past 10 Years?
If Schengen area , which country?
Have you ever been involved in , supported or encouraged terrorist activities in any country?
Have you, by any means or medium, expressed views that justify or glorify terrorist violence or that may encourage others to commit terrorist or other serious criminal acts?
Tell us about work for the following types of organization. Include information for any paid or unpaid or work for the type of organization below. You can select more than one option.
If you needed to add more information about your application but were not able to, you can write it here.
Have you ever been ten printed?
Has anyone ever filed an immigration petition on your behalf with the US?
Do you or did you hold a US Driver's License?
Contact Person Name in the U.S.?
Organization Name in the U.S.?
U.S. Contact Phone Number?
U.S. Contact Email Adress?
Is your father in the U.S.?
Is your Mother in the U.S.?
Do you have any immediate relatives, not including parents in the U.S.?
Do you have any other relatives in the U.S?
Have you attended any educational institutions at a secondary level or above?
Do you belong to a clan or Tribe?
Provide a List of Languages you Speak: