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City
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Manchester
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Country
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UK
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State/Province
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England
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12. Nationality
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UK
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DO NOT WRITE IN THIS SPACE
B-1/B-2 MAX B-1 MAX B-2 MAX
Other
___ Visa Classification
MAX
Mult or
___ Number of Applications
Months
___ Validity
Issued/Refused
On ___
By ___
Under SEC. 214(b) 221(g)
Other ___
INA
Reviewed By ___
13. Sex
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[x]
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Male [] Female
14. National Identification Number (If Applicable)
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CK451729A
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15. Home Address (Include Apartment Number, Street, City, State or Province, Postal Zone and County)
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48 Connie St, Openshaw, Manchester M11 2JT, UK
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16. Home Telephone Number
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+44 121 555 9785
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Business Phone Number
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+44 161 398 0160
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Mobile/Cell Number
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+44 121 742 6182
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Fax Number ___
Business Fax Number ___
Pager Number ___
17. Marital Status
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[x]
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Married [] Single (Never Married) [] Widowed [] Divorced [] Separated
18. Spouse's Full Name (Even if divorced or separated, include maiden name.)
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Elaine Rose Johnson (née Clarence)
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19. Spouse's DOB (dd-mmm-yyyy)
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08 - Apr - 1982
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20. Name and Address of Present Employer or School
Name
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Wilde Aparthotels
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Address
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3 Dickinson St, Manchester, M1 4LF, UK
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21. Present Occupation (if retired, write "retired". If student, write "student".)
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Hotel manager
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22. When do you intend to arrive in the U.S.? (Provide specific date if known) (dd-mmm-yyyy)
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02 - Dec - 2025
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23. E-Mail Address
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24. At what address will you stay in the U.S.?
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8113 Thouron Ave, Philadelphia, PA 19150, USA
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BARCODE
25. Name and telephone numbers of person in U.S. who you will be staying with or visiting for tourism or business: