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APPLICATION FOR IMMIGRANT VISA AND ALIEN REGISTRATION

PART II - SWORN STATEMENT

INSTRUCTIONS: Complete one copy of this form for yourself and each member of your family, regardless of age, who will immigrate with you.

Please print or type your answer to all questions. Questions that are not applicable should be so marked. If there is insufficient room on the form,

answer on a separate sheet using the same numbers as appear on the form. Attach the sheet to this form. DO NOT sign this form until instructed

to do so by the consular officer. The fee for filing this application is listed under tariff item No. 20. The fee should be paid in United States dollars

or local currency equivalent, or by bank draft, when you appear before the consular officer.

WARNING: Any false statement or concealment of a material fact may result in your permanent expulsion from the United States. Even

though you should be admitted to the United States, a fraudulent entry could be grounds for your prosecution and/or deportation.

This form is a continuation of Form OF-230 Part I, which together, constitute the complete Application for Immigrant Visa and Alien

Registration.

24. FAMILY NAME

FIRST NAME

MIDDLE NAME

25. ADDRESS (Local)

26. FINAL ADDRESS TO WHICH YOU WILL TRAVEL IN THE UNITED STATES

(Street Address including ZIP code)

Telephone No.

27. PERSON YOU INTEND TO JOIN (Name, address, and relationship)

28. NAME AND ADDRESS OF SPONSORING PERSON AND EMPLOYER

29. PURPOSE IN GOING TO THE UNITED STATES

30. LENGTH OF INTENDED STAY (If permanently, so state)

31. INTENDED PORT OF ENTRY

32. DO YOU HAVE A TICKET TO FINAL DESTINATION?

Yes

33. United States laws governing the issuance of visas require each applicant to state whether or not he or she is member of an class individuals excluded

from admission into the United States. The excludable classes are described below in general terms. You should read carefully the following list and

answer YES or NO to each category. The answers you give will assist the consular officer to reach a decision on your eligibility to receive a visa.

EXCEPT AS OTHERWISE PROVIDED BY LAW, ALIENS WITHIN THE FOLLOWING

CLASSIFICATIONS ARE INELIGIBLE TO RECIEVE A VISA.

DO ANY OF THE FOLLOWING CLASSES APPLY TO YOU?

a. An alien who has a communicable disease of public health significance, or has or has had a physical or mental disorder that poses, or is

likely to pose a threat to the safety or welfare of the alien or others; an alien who is a drug abuser or addict. [212(a)(1)]

YES

b. An alien convicted of, or who admits committing a crime involving moral turpitude, or violation of any law relating to a controlled

substance; an alien convicted of 2 of more offenses of which the aggregate sentences were 5 years or more; an alien coming to the United

States to engage in prostitution or commercialized vice, or has engaged in prostitution or procuring within the past 10 years; an alien

who is or has been an illicit trafficker in any controlled substance; an alien who has committed a serious criminal offense in the United States

and who has asserted immunity from prosecution. [212(a)(2)]

YES

c. An alien who seeks to enter the United States in espionage, sabotage, export control violations, overthrow of the Govern-

ment of the United States, or other unlawful activity; an alien who seeks to enter the United States to engage an terrorist activities; an alien

who has been a member or affiliated with the Communist or any other totalitarian party; an alien who under the direction of the Nazi

government of Germany, or any are occupied by, or allied with the Nazi government of Germany, ordered, incited, assisted, or otherwise

participated in the persecution of any person because of race, religion, national origin, or political opinion; an alien who has engaged in geno-

cide. [212(a)(3)]

YES

d. An alien who has become a public charge. [212 (a)(4)]

YES

e. An alien who seeks to enter for the purpose of performing skilled or unskilled labor who has not been certified by the Secretary of Labor;

an alien graduate of a foreign medical school seeking to perform medical services who has not passed the NMBE exam or its equivalent.

YES

[212(a)(5)]

Not Applicable

f. An alien previously deported within one year, or arrested and deported within 5 years; an alien who seeks or has sought a visa, entry into

the United States, or any U.S. Immigration benefit by fraud or misrepresentation; an alien who knowingly assisted any other alien to enter

or try to enter into the United States in violation of the law; an alien who is in violation of Section 274C of the Immigration Act. [212(a)(6)]

YES

THIS FORM MAY BE OBTAINED GRATIS AT CONSULAR OFFICES OF THE UNITED STATES OF AMERICA

OPTIONAL FORM 230 II (English)

REVISED 4-91

Previous editions obsolete

DEPT. OF STATE

Application For Immigrant Visa And Alien Registration

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