Palavra - Perseverança

Consular Electronic Application Center - Print Application
8/18/11 12:48 PM
Online Nonimmigrant Visa Application (DS-160)

Application - Sensitive But Unclassified(SBU)
Only print this application for your records. You will not be permitted to submit a printed copy of your application during your interview process.
Photo Provided:
Confirmation Number:
Personal, Address, Phone, and Passport/Travel Document Information

Name Provided:
BALDUSSI ALVES, LUCAS
Full Name in Native Language:
LUCAS BALDUSSI ALVES
Other Names Used:
NO
Telecode Name Used:
NO
Sex:
MALE
Marital Status:
SINGLE
Date of Birth:
15 JUNE 1988
Place of Birth:
CAMBE, PARANA, BRAZIL
Nationality:
BRAZIL
Other Nationalities:
NO
National Identification Number:
92080072
U.S. Social Security Number:
DOES NOT APPLY
U.S. Taxpayer ID Number:
DOES NOT APPLY
Home Address:
AV. ADV. RUI ANTUNES CORREIA, 150

APT 802 BL 01
City:
RIO DE JANEIRO
State/Province:
RIO DE JANEIRO
Postal Zone/ZIP Code:
22793355
Country:
BRAZIL
Same Mailing Address?
YES
Primary Phone Number:
21 8206- 9631
Secondary Phone Number:
21 2437-3929
Work Phone Number:
DOES NOT APPLY
Email Address:
lucas.baldussi@gmail.com
Passport/Travel Document Type:
REGULAR
Passport/Travel Document Number:
FD958574
Passport Book Number:
DOES NOT APPLY
Country/Authority that Issued Passport/Travel Document:
BRAZIL
City Where Issued:
RIO DE JANEIRO
State/Province Where Issued:
RIO DE JANEIRO
Country Where Issued:
BRAZIL
Issuance Date:
20 JUNE 2011
Expiration Date:
19 JUNE 2016
https://ceac.state.gov/GENNIV/common/printapplication.aspx?QRLhzAdbgnLl03e56xoVWDUlsPGpjmcSaJTuHruh%2bwI%3d
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Have you ever lost a passport or had one stolen?
NO
Travel Information
The List of Purposes of Trip to the U.S.
Purpose of Trip to the U.S. (1):
VOCATIONAL/NONACADEMIC
STUDENT (M)
Specify:
STUDENT (M1)
Have you made specific travel plans?
NO
Intended Date of Arrival:
04 SEPTEMBER 2011
Intended Length of Stay in U.S.:
9 MONTH(S)
Address where you will stay in the U.S.:
W. KENOSHA ST.
Person/Entity Paying for Your Trip:
OTHER PERSON
Person Paying for Your Trip:
BALDUSSI , AVELINO
Telephone Number:
43 3255-2267
Email Address:
DOES NOT APPLY
Relationship to You:
PARENT
Is the address of the party paying for your trip the same as your Home
or Mailing Address?
Payer's Address:
Are there other persons traveling with you?
NO
AV. PRESIDENTE BERNARDES
City:
ROLANDIA
State/Province:
PARANA
86600000
Country:
BRAZIL
NO
YES
Have you ever been in the U.S.?

Provide information on your last five U.S. visits:
Date Arrived (1):
02 MAY 1996
Length of Stay:
3 YEAR(S)
Do you or did you hold a U.S. Driver's License?
NO
YES
Have you ever been issued a U.S. Visa?

Date Last Visa was Issued:
16 APRIL 1998
Visa Number:
DO NOT KNOW
Are you applying for the same type of visa?
NO
Are you applying in the same country where the visa above is issued
and is this country your principal country of residence?
YES
Have you been ten-printed?
NO
Has your U.S. Visa ever been lost or stolen?
NO
Has your U.S. Visa ever been cancelled or revoked?
NO
Have you ever been refused a U.S. Visa, been refused admission to the
United States, or withdrawn your application for admission at the port
of entry?
NO
Has anyone ever filed an immigrant petition on your behalf with the
United States Citizenship and Immigration Services?
NO
U.S. Contact Information

Contact Person Name in the U.S.:
DOHNER, LAURA
Organization Name in the U.S.:
RHEMA BIBLE TRAINING CENTER
Relationship to You:
SCHOOL OFFICIAL
U.S. Contact Address:
P.O BOX 50126

TULSA, OKLAHOMA 74150-0126
Phone Number:
(918)258-1588
Email Address:
ldohner@rhema.org
Family Information
Father's Surnames:
ALVES
Father's Given Names:
EDINELSO
Father's Date of Birth:
05 MARCH 1958
Is your father in the U.S.?
NO
Mother's Surnames:
BALDUSSI ALVES
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Mother's Given Names:
ELEONICE
Mother's Date of Birth:
03 FEBRUARY 1965
Is your mother in the U.S.?
NO
Do you have any immediate relatives, not including parents in the

U.S.?
NO
Do you have any other relatives in the United States?
NO
Work/Education/Training Information
Primary Occupation:
NOT EMPLOYED
Explain:
I NOT EMPLOYED AT THE MOMENT DUE TO THE FACT THAT I'M APPLYING TO STUDY
IN THE U.S.A.
YES
Were you previously employed?

Employer Name (1):
TERRA COTA MATERIAIS ELETRICOS
Employer Address:
RUA CEL. JOAO OLINTHO 460
City:
RIO DE JANEIRO
State/Province:
RIO DE JANEIRO
Postal Zone/Zip Code:
22790170
Country:
BRAZIL
Telephone Number:
21 3543-5858
Job Title:
ADMINISTRATIVE ASSISTENT
Supervisor's Surname:
LUIS JUNIOR RANGEL
Supervisor's Given Name:
JUNIOR
Employment Date From:
06 JUNE 2011
Employment Date To:
08 AUGUST 2011
Briefly describe your duties:
- MONITOR PAYMENTS - HELP CUSTOMERS REGARDING PAYMENT ISSUES -PROVIDE

DEILY FINANCIAL REPORTS
Have you attended any educational institutions at a secondary level

or above?
YES
Name of Institution (1):
FACULDADE ESTADUAL DE CIENCIAS ECONOMICAS DE APUCARANA
Address of Institution:
AV. MINAS GERAIS, 5021
City:
APUCARANA
State/Province:
PARANA
86800970
Country:
BRAZIL
Course of Study:
INTERNATIONAL BUSINESS
Date of Attendance From:
03 MARCH 2006
Date of Attendance To:
12 DECEMBER 2009
Do you belong to a clan or tribe?
NO
Provide a List of Languages You Speak:

Language Name: (1):
PORTUGUESE
Language Name: (2):
ENGLISH
Language Name: (3):
SPANISH
Have you traveled to any countries within the last five years?
NO
Have you belonged to, contributed to, or worked for any professional,
social, or charitable organization?
NO
Do you have any specialized skills or training, including firearms,

explosives, nuclear, biological, or chemical experience?
NO
Have you ever served in the military?
NO
Have you ever served in, been a member of, or been involved with a
paramilitary unit, vigilante unit, rebel group, guerrilla group, or
insurgent organization?
NO
Security and Background Information

Do you have a communicable disease of public health significance? (Communicable diseases of public significance include chancroid, gonorrhea, granuloma
inguinale, infectious leprosy, lymphogranuloma venereum, infectious stage syphilis, active tuberculosis, and others diseases as determined by the Department of
Health and Human Services.)
NO
Do you have a mental or physical disorder that poses or is likely to pose a threat to the safety or welfare of yourself or others?
NO
Are you or have you ever been a drug abuser or addict?
NO
Have you ever been arrested or convicted for any offense or crime, even though subject of a pardon, amnesty, or other similar action?
NO
Have you ever violated, or engaged in a conspiracy to violate, any law relating to controlled substances?
NO
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Are you coming to the United States to engage 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 to engage in, money laundering?
NO
Have you ever committed or conspired to commit a human trafficking offense in the United States or outside the United States?
NO
Are you the spouse, son, or daughter of an individual who has committed or conspired to commit a human trafficking offense in the United States or outside the
United States and have you within the last five years, knowingly benefited from the trafficking activities?
NO
Have you knowingly aided, abetted, assisted or colluded with an individual who has committed or conspired to commit a severe human trafficking offense in the
United States or outside the United States?
NO
Do you seek to engage in espionage, sabotage, export control violations, or any other illegal activity while in the United States?
NO
Do you seek to engage in terrorist activities while in the United States or have you ever engaged in terrorist activities?
NO
Have you ever or do you intend to provide financial assistance or other support to terrorists or terrorist organizations?
NO
Are you a member or representative of a terrorist organization?
NO
Have you ever ordered, incited, committed, assisted, or otherwise participated in genocide?
NO
Have you ever committed, ordered, incited, assisted, or otherwise participated in torture?
NO
Have you committed, ordered, incited, assisted, or otherwise participated in extrajudicial killings, political killings, or other acts of violence?
NO
Have you ever engaged in the recruitment or the use of the child soldiers?
NO
Have you, while serving as a government official, been responsible for or directly carried out, at any time, particularly severe violations of religious freedom?
NO
Have you ever been directly involved in the establishment or enforcement of the population controls forcing a woman to undergo an abortion against her free
choice or a man or a woman to undergo sterilization against his or her free will?
NO
Have you ever been directly involved in the coercive transplantation of human organs or bodily tissue?
NO
Have you ever been the subject of a removal or deportation hearing?
NO
Have you ever sought to obtain or assist others 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?
NO
Have you failed to attend a hearing on removability or inadmissibility within the last five years?
NO
Have you ever been unlawfully present, overstayed the amount of time granted by an immigration official or otherwise violated the terms of a U.S. visa?
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. court?
NO
Have you voted in the United States in violation of any law or regulation?
NO
Have you ever renounced United States citizenship for the purpose of avoiding taxation?
NO
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
Student/Exchange Visa Information

Additional Point of Contact Information:
Name (1):
ALVES, EDINELSO
Street Address:
RUA JOSE CANONICO 437
City:
ROLANDIA
State/Province:
PARANA
86600000
Country:
BRAZIL
Telephone Number:
43 3255-5891
Email Address:
edinelsonalves@uol.com.br
Name (2):
BALDUSSI ALVES, ELEONICE
Street Address:
RUA JOSE CANONICO 437
City:
ROLANDIA
State/Province:
PARANA
86600000
Country:
BRAZIL
Telephone Number:
43 32555891
Email Address:
SEVIS ID:
DOES NOT APPLY

N0008531635
Name of School:
RHEMA BIBLE TRAINING CENTER
Course of Study:
BIBLE COURSE
Street Address:
P.O BOX 50126

TULSA, OKLAHOMA 74150-0126
Location Information
Location where you will be submitting your application
Current Location:
RIO DE JANEIRO, BRAZIL
Preparer of Application
Did anyone assist you in filling out this application?
NO
You electronically signed your application on 18-Aug-2011 11:44:22. You were required to electronically sign your application yourself, unless otherwise exempt by regulation, even
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8/18/11 12:48 PM
if the application was prepared by someone other than yourself. Your electronic signature certifies that you have read and understood the questions in this application and that your
answers are true and correct to the best of your knowledge and belief. The submission of an application containing any false or misleading statements may result in the permanent
refusal of a visa or the denial of entry into the United States. All declarations made in this application are unsworn declarations made under penalty of perjury. (28 U.S.C. 1746).
The information that you have provided in your application and other information submitted with your application may be accessible to other government agencies having statutory
or other lawful authority to use such information, including for law enforcement and immigration law enforcement purposes. The photograph that you provide with your application
may be used for employment verification or other U.S. law purposes.
Page 5 of 5

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Consular Electronic Application Center - Print Application

Online Nonimmigrant Visa Application (DS-160)

Personal, Address, Phone, and Passport/Travel Document Information

BALDUSSI ALVES, LUCAS

Full Name in Native Language:

LUCAS BALDUSSI ALVES

Other Names Used:

Telecode Name Used:

CAMBE, PARANA, BRAZIL

National Identification Number:

U.S. Social Security Number:

DOES NOT APPLY

U.S. Taxpayer ID Number:

DOES NOT APPLY

AV. ADV. RUI ANTUNES CORREIA, 150

Postal Zone/ZIP Code:

Same Mailing Address?

Primary Phone Number:

Secondary Phone Number:

Work Phone Number:

DOES NOT APPLY

Passport/Travel Document Type:

Passport/Travel Document Number:

Passport Book Number:

DOES NOT APPLY

Country/Authority that Issued Passport/Travel Document:

City Where Issued:

State/Province Where Issued:

Country Where Issued:

Consular Electronic Application Center - Print Application

Have you ever lost a passport or had one stolen?

Have you made specific travel plans?

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:

Person Paying for Your Trip:

DOES NOT APPLY

Are there other persons traveling with you?

Postal Zone/ZIP Code:

Have you ever been in the U.S.?

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

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

Are you applying for the same type of visa?

Have you been ten-printed?

Has your U.S. Visa ever been lost or stolen?

Has your U.S. Visa ever been cancelled or revoked?

U.S. Contact Information

Organization Name in the U.S.:

RHEMA BIBLE TRAINING CENTER

U.S. Contact Address:

P.O BOX 50126

Father's Given Names:

Father's Date of Birth:

Is your father in the U.S.?

Consular Electronic Application Center - Print Application

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

Do you have any other relatives in the United States?

Were you previously employed?

TERRA COTA MATERIAIS ELETRICOS

RUA CEL. JOAO OLINTHO 460