LAW OFFICE OF GWENDOLYN M SANTOS Los Angeles * Riverside DS- 160 CLIENT IN-TAKE SHEETLINFORMATION RE. APPLICANT Name :__¢HRISTIMA ANG ELE HAGLAQUL Other names used (if applicable) 7Heewr_¢! carisTY ): 4199 PREY. CALIOS, STA-CkUY, LACK A ~ YEOI Date on Births eat 4:2) Mera h/. Oka issih he Soesiee otal Place of Birth: PAM AY CTY Marital Status: MARRIED Passport Numbers 2X\i01) 4003 2a eee Place of Issuance: JFH tewsurak OFFIe€ - RCRA Expiration: lou: L Philippine Address (with postal code) 1-94: Expiration: Have you ever had a passport lost or stolen? Me ee Home Phone: 2 ea Le USS Work Phone: Work Fax: Email address: US NATIONAL IDENTIFICATION NO. US TAX ID NO. US SS NO.HAVE YOU EVEN BEEN ISSUED A US VISA? Mo HAVE YOU EVER BEEN REFUSED A US VISA, BEEN REFUSED ADMISSION TO THE US, OR WITHDRAWN YOUR APPLICATION FOR ADMISSION AT THE POINT OF ENTRY? IF YES, PLEASE PROVIDE DETAILS. __/i/e IV. US CONTACT INFORMATION CONTACT PERSON NAME INTHE US __AUcfw Aye eter ORGANIZATION NAME IN THE US RELATIONSHIP TO YOU Beet Hee US CONTACT ADDRESS Lave BO? OB OT ~ 726 PHONE NAME 102 ~ 247 ~e {4 EMAIL ADDRESS _odh gud @ yakeo com IILY INI FATHER'S SURNAME AWG ELES. FATHER'S GIVEN NAMES ___LILDA Zico Aw CETES FATHER’S BIRTHDATE taly 04 [919 IS YOUR FATHER IN THE US? _ Dever &p MOTHER'S SURNAME DILINILA MOTHER'S GIVENNAMES_ A A//77) MOTHER'S BIRTHDATE Vuly 26/935 IS YOUR MOTHER INTHE US?___ Ao DO YOU HAVE IMMEDIATE RELATIVES IN THE US, NOT INCLUDING YOUR PARENTS? — juywer