Consular Electronic Application Center - Print Application 4t664i

29/10/2010

Consular Electronic Application Center -…

Nonimmigrant Visa Application Application - Sensitive But Unclassified(SBU)

Photo Provided:

C onfirmation Number:

Personal, Address, Phone, and port Information Name Provided: Full Name in Native Language: Other Names Used:

SANC HEZ GUDINO , C AROL JOSEFINA C AROL JOSEFINA SANC HEZ GUDINO NO

Sex: Marital Status: Date of Birth: Place of Birth: Nationality: Other Nationalities:

FEMALE MARRIED 21 JUNE 1978 C ORO , FALC ON , VENEZUELA VENEZUELA NO

National Identification Number: U.S. Social Security Number: U.S. Taxpayer ID Number: Home Address:

13593204 DOES NOT APPLY DOES NOT APPLY C ONJUNTO RESIDENC IAL VILLA MARIA C ALLE APAMATE C ASA 2 C ORO FALC ON 4101 VENEZUELA YES 02689894434 02682532781 02682532781 04246254915 [email protected] 002236700 DOES NOT APPLY VENEZUELA C ORO FALC ON VENEZUELA 14 AUGUST 2007 13 AUGUST 2012 NO

C ity: State/Province: Postal Zone/ZIP C ode: C ountry: Same Mailing Address? Home Phone Number: Work Phone Number: Work Fax Number: Mobile/C ell Phone Number: Email Address: port Number: port Book Number: C ountry/Authority that Issued port: C ity Where Issued: State/Province Where Issued: C ountry Where Issued: Issuance Date: Expiration Date: Have you ever lost a port or had one stolen?

Travel Information Principal Applicant?

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YES

Purpose of Your Trip to U.S. Purpose (1) :

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BUSINESS/PERSONAL TRAVEL (B1, B2)

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Intended Date of Arrival: Intended Length of Stay in U.S.: Address where you will stay in the U.S: Person/Entity Paying for Your Trip: Name of Person Paying for Your Trip: Telephone: Email Address: Relationship to You: Is the address of the party paying for your trip the same as your Home or Mailing Address?

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Other Persons Traveling with You:

YES

Are you traveling as part of a group or organization? Persons Traveling with You: Name (1) : Relationship to You:

NO

Name (2) : Relationship to You:

C HIRINO SANC HEZ , C ARLOS LUIS C HILD YES

Have you ever been in the U.S.? Previous U.S. Visits in the last 5 years: Travel Date of Arrival (1) : Length of Stay:

Do you or did you hold a U.S. Driver's License?

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20 AUGUST 2011 20 DAY(S) 7751 BLAC K LAKE ROAD KISSIMMEE ORLANDO, FLORIDA 34747 OTHER PERSON C HIRINO ZARRAGA , C ARLOS AUGUSTO 04146845048 [email protected] SPOUSE YES

Have you ever been issued a U.S. Visa?

C HIRINO ZARRAGA , C ARLOS AUGUSTO SPOUSE

01 JULY 2008 21 DAY(S) NO YES

Date Last Visa was Issued: 05 JUNE 2009 Visa Number: 56014788 Are you applying for the same type of visa? YES Are you applying in the same country where YES the visa above is issued and is this country your principal country of residence? Have you been ten-printed? YES Has your U.S. Visa ever been lost or stolen? NO Has your U.S. Visa ever been cancelled or NO revoked? Have you ever been refused a U.S. Visa, been refused ission to the United States, or withdrawn your application for ission at the point of entry?

NO

U.S. Information C ontact Person Name in the U.S.: Organization Name in the U.S.: Relationship to You: U.S. C ontact Address:

Phone Number: Email Address:

HOTEL, HOTEL HOTEL OTHER HOTEL HOTEL ORLANDO, FLORIDA 34747 (800)230-4134 DOES NOT APPLY

Family Information Father's Surnames: Father's Given Names: Father's Date of Birth: Is your father in the U.S.? Mother's Surnames: Mother's Given Names: Mother's Date of Birth: 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 United States? Spouse's Full Name:

ceac.state.gov/…/printapplication.aspx?…

SANC HEZ QUINTERO REINALDO ANTONIO 02 JANUARY 1942 NO GUDINO DE SANC HEZ FANNY JOSEFINA 07 NOVEMBER 1957 NO NO NO C HIRINO ZARRAGA , C ARLOS AUGUSTO

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29/10/2010 Spouse's Spouse's Spouse's Spouse's Spouse’s

Consular Electronic Application Center -…

Date of Birth: Nationality: C ity of Birth: C ountry of Birth: Address:

06 SEPTEMBER 1974 VENEZUELA C ORO VENEZUELA SAME AS HOME ADDRESS

Work / Education / Training Information Primary Occupation: Specify Other: Present Employer or School Name: Address: C ity: State/Province: Postal Zone/Zip C ode: C ountry: Month Salary in Local C urrency: Briefly Describe your Duties:

OTHER LIC ENC IADA EN ISTRAC ION ARQUIPROYEC AVENIDA LOS MEDANOS C ENTRO C OMERC IAL LAS TEJAS LOC AL 2 C ORO FALC ON 4101 VENEZUELA 5,000 A DE OBRAS

Security and Background Information Do you have a communicable disease of public NO health significance such as tuberculosis (TB)? Do you have a mental or physical disorder that NO poses or is likely to pose a threat to the safety or welfare of yourself or others? Are you or have you ever been a drug ab or NO addict? Have you ever been arrested or convicted for NO any offense or crime, even though subject of a pardon, amnesty, or other similar action? Have you ever violated, or engaged in a NO conspiracy to violate, any law relating to controlled substances? Are you coming to the United States to engage NO in prostitution or unlawful commercialized vice or have you been engaged in prostitution or procuring prostitutes within the past 10 years? Have you ever been involved in, or do you seek NO to engage in, money laundering? Do you seek to engage in espionage, sabotage, NO export control violations, or any other illegal activity while in the United States? Do you seek to engage in terrorist activities NO while in the United States or have you ever engaged in terrorist activities? Have you ever or do you intend to provide NO financial assistance or other to terrorists or terrorist organizations? Are you a member or representative of a NO terrorist organization? Have you ever ordered, incited, committed, NO assisted, or otherwise participated in genocide? Have you ever committed, ordered, incited, NO assisted, or otherwise participated in torture? Have you committed, ordered, incited, assisted, NO or otherwise participated in extrajudicial killings, political killings, or other acts of violence? Have you, while serving as a government NO official, been responsible for or directly carried out, at any time, particularly severe violations of religious freedom? Have you ever been the subject of a removal or NO deportation hearing? Have you ever sought to obtain or assist others NO 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 failed to attend a hearing on NO removability or inissibility within the last five years?

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Have you ever been unlawfully present, overstayed the amount of time granted by an immigration official or otherwise violated the of a U.S. visa? 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. 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? Have you attended a public elementary school on student (F) status or a public secondary school after November 30, 1996 without reimbursing the school?

NO

NO

NO NO NO

Location Information C urrent Location:

C ARAC AS, VENEZUELA

Preparer of Application: Did anyone assist you in filling out this application?

ceac.state.gov/…/printapplication.aspx?…

NO

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