Dear Visa Applicant,

As part of your administrative processing, please provide the following information:

Type this information directly in the body of the email, NOT as an attachment. Please do NOT use a table format. Insert each response directly under the question.

Please submit all required documents in a single PDF format, which should be up to 2MB.

۱٫ List all countries you have traveled to (other than your country of residence) in the last 15 years. For each trip, provide details for locations visited, dates visited, source of funds, and length of stay.

۲٫ List all of your previous passport number(s) and country of issuance.

۳٫ List all names and dates of birth of all immediate relatives not recorded in your visa application, including:

• Siblings (full, half, step, and adopted brothers and sisters, living or deceased);

• Children (natural, step, and adopted children, including minor and adult, living or deceased); and

• Spouse (current or previous spouse or civil/domestic partner, living or deceased).

۴٫ List all of your addresses during the last 15 years, if different from your current address, including dates of residence. Please include street address, city, postal zone/zip code and country.

۵٫ List all phone numbers, email addresses, and social media account user names (e.g. IMO, Telegram, Twitter, Instagram, Facebook, Viber, Snapchat, etc.) you have used in the last 5 years. Do not list accounts designed for use by multiple users within a business or other organization. Do NOT provide any account passwords!

۶٫ List the following information on all employment in the last 15 years:

a. Employer name

b. Dates of employment

c. Address and telephone number

d. Job title

e. Job description

۷٫ Have you belonged to, contributed to, or worked for any professional, social, or academic organization, such as the National Elites Foundation?

۸٫ Please attach an electronic copy of your CV, including your entire education and work history.

۹٫ If you are a male applicant, please provide the following information:

• Did you serve in the Iranian Military?

If YES,

۱٫ In which branch did you serve – Artesh (Ground, Air, or Navy), IRGC (Ground, Air, or Navy), or Police?

۲٫ Where did your service take place (i.e. Tehran, Esfahan, etc.)?

۳٫ When did you begin and end your military service? Please explain any reductions in time served.

۴٫ What was your rank at the time you completed your military service?

۵٫ What were your duties and responsibilities?

۶٫ If you performed an alternative service, such as a research project with National Elites, please provide the branch, dates, and location of any military training you received.

۷٫ Please provide a scan copy of your original military completion card.

If NO,

۱٫ What were your reasons for exemption?

۲٫ Was any period of training or service required prior to the exemption? If so, provide the branch, dates, and locations.

۳٫ Please provide a scan copy of your original military exemption card.

Were you a member of Basij?

If YES, please provide the dates and location of your training and membership.

Please provide a scan copy of your military service card or exemption card (both sides), along with official translation. If you are currently exempt for ongoing education, please provide documentation detailing the bond you paid to depart Iran, with English translation.

۱۰٫ APPLICANT’S CERTIFICATION:

I understand all the information I have provided in, or in support of, this application may be provided to other U.S. government agencies authorized to use such information for purposes including enforcement of the laws of the United States. I understand all of the information contained in this form and I certify under penalty of perjury under the laws of the United States of America that the foregoing is complete, true, and correct. I understand that any willfully false or misleading statement or willful concealment of a material fact made by me herein may result in refusal of the visa, denial of admission to the United States, and, may subject me to criminal prosecution and/or removal from the United States.

• Type your full name to certify your agreement with the statement above:

• Date of certification:

In addition, please also provide an approximate date when you plan to travel to the U.S.

Sincerely,

Consular Section

U.S. Embassy Yerevan | 1 American Ave, Yerevan 0082, Armenia