Consular Electronic ApplicationCenter print Application

C'rp.1 uz 4

Nonimmigrant Visa Application Application- Sensitive Unclassified(SBU) But PhotoProvided:

Confirmation Number:

Personal, Address, phone, and Passport fnformation

NameProvided: FullNamein NativeLancuaae: ft l l Ll OtherNamesUsed: OtherName(1) : Sex; Marital Status: Dateof Birth: Place Birth: of Nationality: OtherNationalities: National Identification Number: U.S.Social SecurityNumber: U.S.Taxpayer Number: ID HomeAddress: City; State/Province: PostalZonelZIP Code: Country: SameMailing Address? HomePhone Number: Work Phone Number: Work Fax Number: l4obile/Cell PhoneNumber: EmailAddress: Passport Number: Passport BookNumber: Country/Authority Issuedpassport: that City WhereIssued: State/Province WhereIssued : CountryWhereIssued: Issuance Datei Expiration Date: Haveyou ever lost a passport had one or stolen? KHODOROVSKAYA , XENIYA XOAOPOBCKAF. KCEHUq AH,qPEEBHA YES BUKINICH XENIYA , FEI'IALE SINGLE 23APRIL 991 1 ALMATY, ALMATYNSKAYA, KAZAKHSTAN KAZAKHSTAN NO o22160920 DOES NOTAPPLY DOES NOTAPPLY VITEBSKAYA APT77 76, ALMATY ALT4ATINSKAYA 050023 KAZAKHSTAN YES 7-7 27 -293-34-24 DOES NOTAPPLY DOES NOTAPPLY 7-7 77-2257 99a ang n_dev666@mail. ru N06483011 DOES NOTAPPLY KAZAKHSTAN MIA KAZ ALMATY KAZAKHSTAN 3ONOVEMBER 2OO9 29 NOVEMBER19 20 NO

Travel Information
Principal Applicant? LJ

i^-l Purpose YourTrip to U.S. of

YES

https://ceac.state.gov/GENNlVicommon/printapplication.aspx?guy1a5yrGw6x%2b7...25.03.2010

Electronic ApplicationCenter PrintApplication . Consular

(1) Purpose : IntendedDateof Arrival: IntendedLengthof Stay in U.S.: Address whereyou will stay in the U.S: Person/Entity Paying YourTrip: for Nameof Person Paying YourTrip: for TeleDhone: EmailAddress: RelationshiD You: to Is the address the party payingfor your trip of the sameas your Homeor Mailing Address? OtherPersons Traveling with You: VISA STUDENT/EXCHANGE (F, J, M, Q) 2010 10 JUNE 3 MONTH(S) 7487 4 AVE WISCONSIN 54909 ALI4OND, PERSON OTHER KHODOROVSKIY , ANDREY 7-705-8763313 DOES NOTAPPLY PARENT YES NO

C:rp.2uz 4

YEs

LJ Haveyou ever beenin the U.S.? Previous U.S.Visitsin the last 5 years: 01 IUNE2005 TravelDate of Arrival(1) : 3 MONTH(S) Lengthof Stay: Do you or did you hold a U,S. Driver'sLicense? NO YES Haveyou ever beenissueda U.S.Visa? Ll 24 MAY2005 ' Date LastVisawas Issued: DO NOTKNOW VisaNumber: for Are you applying the sametype of visa? No YES Are you applying the same country in wherethe visa aboveis issuedand is this countryyour principal countryof residdnce? NO Havevou beenten-orinted? No Hasyour U.S.Visaever beenlost or stolen? or NO Hasyour U.S.Visaever beencancelled revoked? Haveyou ever beenrefuseda U.S.Visa,been No to refused admission the UnitedStates,or your application admission the at withdrawn for Dointof entrv?

U.S, Contact Inforlhation

Person Namejn the U.S.: Contact Namein the U.S.: Organization Relationship You: to U.S. ContactAddress: Phone Number: EmallAddress: CHIP KEDROWICZ, RAINBOWVALLEY EMPLOYER 7487 4 AvE WISCONSIN 54909 ALMOND, (7tS)340-3541 com kedrowiczr@Aol KHODOROVSKIY ANDREY 1967 07 DECEMBER No BUKINICH TATYANA 12 MAY1958 NO NO YES

Family Information
Father's Surnames: Father's GivenNames: Father's Dateof Birth: Is your father in the U.S.? Mother's Surnames: N4other's GivenNames: Mother's Dateof Birth; Is your motherin the U.S.? not relatives, Do you haveany immediate parentsin the U.S,? including in Do you haveany other relatives the United States? Primary Occupation: Present Emolover SchoolName: or Address: C'ty: State/Province:

Work / Education / Training Information

STUDENT KHAN NAMED AFTER ABYLAY UNIVERSITY KAZAKH 200 MURATBAEVA SHEVCHENKO ALMATY ALMAATINSKAYA

https://ceac.state.gov/GENNIV/common/printapplication.aspx?8uYla5yrGw6Xo/o2b7...25.03.201

Consular Electronic ApplicationCenter PrintApplication

Postal ZonelzipCode: Country: f4onthSalaryin LocalCurrency: ErieflyDescribe your Duties: Wereyou previously employed? DOES NOTAPPLY KAZAKHSTAN NOTAPPLY DOES STUDENT NO

Crp. 3 ur 4

Security and Background Information

Do you havea communicable disease public NO of healthsigniflcance (TB)? suchas tuberculosis Do you havea mentalor physical disorder that NO posesor is likelyto posea threat to the safety or welfareof yourselfor others? ATeyou or haveyou ever beena drug abuseror NO addict? Haveyou ever beenarrestedor convicted for NO any offense crime,even though subjectof a or pardon,amnesty, other similaraction? or Haveyou everviolated,or engagedin a NO conspiracy violate,any law relatingto to controlled substances? Are you comingto the UnitedStatesto engage NO in prosutution unlawfulcommercialized or vice or haveyou beenengaged prostitution in or procuring prostitutes within the past 10 years? Haveyou ever beeninvolvedin, or do you seek NO to engagein, moneylaundering? Do you seekto engagein espionage, sabotage, NO exportcontrolviolations, any other illegal or activitywhilein the UnitedStates? Do you seekto engagein terroristactivities NO whilein the UnitedStatesor have you ever jn engaged terroristactivities? Haveyou ever or do you intendto provide NO financial assistance other supportto terrorists or or terroristorganizations? Are you a memberor representatjve a of NO terroristorganization? Haveyou ever ordered,incited,committed, NO participated genocide? assisted, otherwise or in Haveyou ever committed, ordered,incited, NO participated torture? assisted, otherwise or in Haveyou committed, ordered,incited,assisted,NO participated extrajudicial or otherwise in killings, political killings, other acts of violence? or Haveyou, whileservingas a government NO official, beenresponsible or directlycarried for out, at any time, particularly severeviolations of religious freedom? Haveyou ever beenthe subjectof a removalor NO deportation hearing? Haveyou ever soughtto obtainor assistothers NO to obtaina visa,entry into the UnitedStates,or any other UnitedStatesimmigration benefitby fraud or willfulmisrepresentation other or unlawfulmeans? Haveyou failedto attenda hearingon NO removability inadmissibility or within the last five years? Haveyou ever beenunlawfully present, NO overstayed amountof time grantedby an the immigration official otherwise or violatedthe terms of a U.S.visa? Haveyou ever withheldcustodyof a U.S.citizenNO childoutsidethe united Statesfrom a person grantedlegalcustodyby a U.S.court? Haveyou voted in the UnitedStatesin violation NO of any law or regulation? Haveyou ever renounced UnitedStates NO citizenship the purpose avoiding for of taxation? Haveyou attended publicelementary a school NO

h@s://ceac.state.gov/GENNIV/common/printapplication.aspx?8uY1a5yrGw6X%2b7...25.03.2

'

ConsularElectronicApplication Center- Print Application

on student(F) statusor a publicsecondary schoolafter November 30, 1996 without reimbursing school? the

'Crp.4us4

Student/Exchange Visa Information

LlAdditionalPointof ContactInformation: Name(l): Street Address: City: State/Province: Postal zonelzlP Code: ' Country: Telephone Numbbr: EmailAddress: Name(2): Street Address: Citv: State/Province: Postal ZonelZIPCode: Country: Telephone Number: EmailAddress: SEVISID: Do you intendto study jn the U.S.? KoSTINUK, NATALIYA KOKTEM-I2L, APT32 ALMATY DOESNOTAPPLY NOTAPPLY DOES KAZAKHSTAN DoESNOTAPPLY DOES NOTAPPLY LARISSA MELNIKOVA, 20, HADZHIMUKANA APf 24 ALMATY DOESNOTAPPLY 050059 KAZAKHSTAN DOES NOTAPPLY NOTAPPLY DOES N0006952092 NO KAZAKHSTAN ALMATY, NO

LocatlonInformation
Current Location:

Preparer of Application:
Did anyoneassistyou in fillingout this aoolication?

https://ceac.state.gov/GENNlV/common/printapplication.aspx?8uY1a5yrGw6X%2b7...25.03.2010