First Name:Srdan________________Last Name:____Blatesic_____________________

Name of your grandmother; your mom's mom (mandatory response on a security question to
run your application for visa) ______Stojanka_________________________
1.Marriage status:(Single / married / divorsed / widowed)
If you are divorced-name and surname of the former wife, date, year, place and country of
birth, current address of residence, date of conclusion and dissolution of marriage
2. Date of Birth______________
3. Place of Birth______________
4. Nationality by passport___________________
5. Do you have any other passport in addition to the current? (If you have a number of this
other passport)__________________
6. Address of residence_________________
If you live at a different address than the one listed on your passport ,please write
7. Number of your mobile phone______________ And if you have a stabile telephone
___________mail address______
8. Passport number___________
9. When the passport was issued _______________when expires_____________
10. In which city passport was issued ________________
11. Have you ever been lost or stolen passport, and if so, when and in what circumstances
_____________________________________
12. Have you ever been in America
And if so,
when (date of entry into the USA) ___________, what kind of visa did you
hold____________ and how long did you stay ___________ (days, months, years)
If you are a seaman, just passed through the United States, please write exact dates of
embarking (the beginning of contract) and disembarking (end of contract) in America
13. Date of issuance of the last US visa; if any visas before, the number of visa?
_________________________________
Number of visa is a red number that consists of both letters and numbers

14. Have you ever been refused a visa for the US, and if so when, what kind of visa and why?
______________________________________
15. Have you ever had / do you have a US driver's license (if yes please write the number and
the place of issuance)?___________________________
16. Name and surname of your father and his date of
birth:_______________________________
17. Name and surname of the mother and her date of birth:
____________________________________
18. Do you have any of close or distant relatives in America; if so, who and what is their legal
status in USA?
____________________________________
19. Do you talk any other foreign language besides English?
____________________________________
20. Are you employed or not?
If you are not please write details of previous employer:
_________________ company name, address of the company __________, supervisor's
name_______________, the position you have been working at ____________, the date of
beggining of employment _______________, end date of employment_______________
If you are employed, please write details for current employer:
_________________ company name, address of the company __________, supervisor's
name_______________, the position you have been working at ____________, the date of
beggining of employment _______________, end date of employment_______________
21. Were you ever arrested or criminally charged________________________________
22.Did you serve in army?if yes in which country and what was the rank and dates of service
_______________________________________________________________________
23. In which country you will go to the American Embassy?_______________________
Fill in the country if it is different from the country of your nationality

24.What kind of school/university did you finish and dates of start and end of education
_______________________________________________________________________

25.Data related to future employment:

Company Name _______________, _______________ Ship name, date of embarkation
___________, the position that you are hired for___________________
Thank you