1) Do you have a physical or mental disorder; or are you a drug abuser
or addict; or do you currently have any of the following diseases:
O Yes / O No
Chancroid
Gonorrhea
Granuloma Inguinale
Leprosy, infectious
Lymphogranuloma venereum
Syphilis, infectious
Active Tuberculosis
2) Have you ever been arrested or convicted for a crime that resulted in
serious damage to property, or serious harm to another person or
government authority?
O Yes / O No
3) Have you ever violated any law related to possessing, using, or distributing
illegal drugs?
O Yes / O No
4) Do you seek to engage in or have you ever engaged in terrorist activities,
espionage, sabotage, or genocide?
O Yes / O No
5) Have you ever committed fraud or misrepresented yourself or others to
obtain, or assist others to obtain, a visa or entry into the United States?
O Yes / O No
6) Are you currently seeking employment in the United States or were you
previously employed in the United States without prior permission from the
U.S. government?
O Yes / O No
7) Have you ever been denied a U.S. visa you applied for with your current or
previous passport, or have you ever been refused admission to the United
States or withdrawn your application for admission at a U.S. port of entry?
O Yes / O No
If Yes
when _______________
where _______________
8) Have you ever stayed in the United States longer than the admission
period granted to you by the U.S. government?
O Yes / O No
