Form  A.  Application  and  Eligibility  Survey  

 
 
INSTRUCTIONS:  Please  fill  out  the  form  using  print  letters.  Put  a  cross  on  the  box  for  your  answer.  Put  n/a  if  it  does  not  apply  to  you.  
Don’t  leave  anything  blank.  Avoid  erasures.  For  dates,  please  follow  the  format  DD/MM/YYYY.  Example:  JANUARY  30,  1995  –  
30/01/1995.  
PERSONAL  INFORMATION  
Last  Name:   ZAFRA
Middle  Name:   OCAMPO
First  Name:   ANGELINO JR
Gender: Female  
Date  of  Birth  (DD/MM/YYYY):  23/03/1994
  Age:  23 X Male   Marital  Status:   X Single   Married  
Citizenship:  X Filipino   Others:  
______________________   (If  foreigner)  Type  of  Visa  in  the  Philippines:  
City  of  Birth:   SAN RAFAEL, BULACAN Country  of  Birth:   PHILIPPINES
PERSONAL  CONTACT  DETAILS  
Landline  (with  area  code):   Mobile  Number:    
E-­‐mail  Address:   zafra_mok@yahoo.com E-­‐mail  used  in  Facebook:   zafra_mok@yahoo.com
Facebook  Username:   Mok Zafra Instagram  Username:   Skype  ID:   mokzafra
Present  Address  (Mailing  Address):   Doha, Qatar
Postal  Code:   City  &  Province:     Country:   Qatar
Permanent  Address  (If  different  from  Present  Address):   San Rafael, Bulacan
Postal  Code:   3008 City  &  Province:     BULACAN Country:   Philippines
EDUCATIONAL  BACKGROUND  
Are  you  enrolled  in  a  4-­‐year  course  as  a  full-­‐time  student?   Yes   X No:  ____________________________(working  student,  masteral,  
doctoral,  etc.)  
University/College  (full  university  name  with  campus,  city,  and  province):   Baliuag University, Baliuag Bulacan
Degree/Course:   BS Hospitality Management Year   L evel:   (graduate) Graduation  Year:   2014
SELF-­‐ASSESSED  ENGLISH  PROFICIENCY  
Oral  Ability:   Beginner   Intermediate   X Advanced   Fluent  
Written  Skills:   Beginner   Intermediate   XAdvanced   Fluent  
Listening/Comprehension  Skills:   Beginner   Intermediate   X Advanced   Fluent  
TRAVEL  INFORMATION  
Do  you  have  a  passport?   X Yes  
No   (If  you  do  not  have  a  passport  yet)  When  is  your  DFA  Appointment?  
Passport  Number:     Passport  Issue  Date  (DD/MM/YYYY):   Expiry  Date  (DD/MM/YYYY):   Issuing  Country:  
Have  you  ever  travelled  outside  the  Philippines  Before?  
X Yes   No   If  yes,  where?   Qatar
Have  you  ever  applied  for  a  visa  for  any  country  except  US?   Yes   X No  
List  the  Countries  you  have  applied  for  
Type  of  Visa   Result:  Approved/Denied  
a  Visa  (except  US)  
  Qatar   Working   Approved
     
     
     
     
Have  you  ever  applied  for  a  US  Visa  before?   Yes   XNo   Date  of  Last  Application  (DD/MM/YYYY):  
Type  of  US  Visa  you  last  applied  for?   Immigrant   Non-­‐
immigrant   Was  it  Approved?   Yes   No  

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     Form  A.  Application  and  Eligibility  Survey  
 
  
  Form  A.  Application  and  Eligibility  Survey  
 
If  Immigrant  Visa  (IV),  name  of  petitioner  and  relationship  to  you:  
Current  Status  of  IV:   In  Process   Pulled  Out  
Immigrant  Case  Tracking  Number  (e.g.  MTL1999626025): Cancelled/Denied   Approved  
If  Non-­‐Immigrant  Visa  (NIV),  what  type  of  visa  (tourist,  student,  working,  etc.):  
Is  your  NIV  still  valid? Yes   No:  _____________________  
Expiration  Date  of  your  NIV  (DD/MM/YYYY):  
(revoked,  cancelled,  expired)  

MEDICAL  AND  OTHER  HISTORY  

Did  you  ever  have  a  medical  condition  that  required  doctor’s  clearance  in  the  past?   Yes   X No  
If  yes,  what  is  it?   Is  it  still  recurring? Yes   No  
Do  you  have  any  medical/physical  condition  that  would  prevent  you  from  performing  certain  tasks  (mild  seizures,  cerebral  palsy,  
asthma,  scoliosis,  etc.)? Yes   X No  
Please  indicate  the  medical  condition  and  the  activities  you  cannot  do:  
  N/A
Have  you  ever  been  issued  a  verbal/written  warning  and/or  suspension  from  your  University/College?   Yes   XNo  
Have  you  ever  been  arrested  and/or  convicted  of  a  crime?   Yes   XNo  
Have  you  ever  been  refused  entry  into  any  country?   Yes   XNo  
For  Female  candidates,  Are  you  pregnant?   Yes   No  
 
 
 
FAMILY  BACKGROUND  
Father’s  Complete  Name:   Angelino C. Zafra Sr.
Father’s  Mobile  Number:   Father’s  E-­‐mail  Address:  
Father’s  Occupation:   OFW Company  Name:   Johnson and Johson
Father’s  Office  Address:   Dubai
Father’s  Office  Number:  
Mother’s  Complete  Name:   Leilani O. Zafra
Mother’s  Mobile  Number:   Mother’s  E-­‐mail  Address:  
Mother’s  Occupation:   OFW Company  Name:  
Mother’s  Office  Address:  
Mother’s  Office  Number:  
(If  not  living  with  parents)    
Guardian’s  Complete  Name:   Relationship  to  you:  
Guardian’s  Mobile  Number:   Guardian’s  E-­‐mail  Address:  
Guardian’s  Occupation:   Company  Name:  
Guardian’s  Office  Address:  
Guardian’s  Office  Number:  
Other  Immediate  Relatives  (not  listed  above):  
Name  of  Brother/s,   School/University  or  
Relationship   Age   Course/Profession  
Sister/s,  Children   Employer  
1.   Angenie Marie Zafra  Sister   24   HRM, BSED/ housewife  
BS
2.  Lance Angelo Zafra  Brother   17   Student  
3.          
4.          
5.          
6.          
7.          
   

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     Form  A.  Application  and  Eligibility  Survey  
 
  
  Form  A.  Application  and  Eligibility  Survey  
 
Do  you  have  relatives  in  the  USA? Yes   X No  
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If  yes,  please  list  down  ALL  your  relatives  (up  to  the  3  degree)  in  the  USA.  
 
Number   Status:  Citizen,  Immigrant,  
Current  Location  
Relationship  to   Contact   of  years   Non-­‐immigrant,  Out  of  
Name  of  Relative   in  the  USA  
You   Information   living  in   Status,  Undocumented,  
(address)  
the  USA   etc.  
1.            
2.            
3.            
4.            
5.            
6.            
7.            
8.            
9.            
10.            
     
List  down  relatives  in  the  Philippines  who  currently  employed  
Relationship  to   Contact   Current   ID  provided,  Proof  of  
Name  of  Relative   Current  Address  
You   Information   Employment   Billing  provided  
1.            
2.            
3.            
4.            
5.            
6.            
7.            
8.            
9.            
10.            
     
CONFORME  
I  hereby  certify  that  all  details  and  information  above  are  true  and  accurate.  Any  false  data  may  result  to  program  cancellation  
for  the  WAT  Program.  I  understand  and  know  that  all  of  the  details  in  this  form  will  be  treated  with  utmost  confidentiality  by  
United  Towers  Philippines.    
Participant  Full  Name:   ANGELINO O. ZAFRA JR.
Participant  Signature:  
Date  of  Signing  (DD/MM/YYYY):   11/08/2017
Noted  by:  
Parent/Guardian’s  Full  Name:  
Parent/Guardian’s  Signature:  
Date  of  Signing  (DD/MM/YYYY):  
 

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     Form  A.  Application  and  Eligibility  Survey