Personal Information

In the Family Name field, enter your family name as the family name appears on your passport under the Family Name or Surname field. The family name is required to complete the application.
Family Name cannot be blank.
In the First (Given) Name field, enter your first (given) name as the first name appears on your passport under the First or Given Name field. Do not include the middle name in this field. The first name is required to complete the application. If you have no first name, then enter the letters FNU which stands for First Name Unknown.
First (Given) Name cannot be blank.
Middle Name cannot be blank.
Choose your gender, either male or female. The gender is required to complete the application.
Gender cannot be blank.
Enter the city, town, village, or hamlet in which you were born. The city, town, village, or hamlet where you were born is required to complete the application. If you do not know the city in which you were born, enter UNKNOWN.
City of Birth cannot be blank.
Choose the country in which you were born. The country where you were born is required to complete the application.
Country of Birth cannot be blank.
In the Day field, choose the day on which you were born. The day of birth is required to complete the application or to check the status of your application. In the Month field, choose the month in which you were born. The month of birth is required to complete the application or to check the status of your application. In the Year field, choose the year in which you were born. The year of birth is required to complete the application and to check the status of your application.
Date of Birth cannot be blank.

Passport Information

English characters only - AS IN YOUR PASSPORT!!

Choose the country of citizenship, as it appears on your passport. The passport issuing country is required to complete the application.
Issuing Country cannot be blank.
Enter your passport number as it appears on your passport. The passport number may contain numbers and/or characters. Please closely distinguish between the number zero and the letter O. The passport number is required to complete the application or to check the status of your application.
Passport Number cannot be blank.
In the Day field, choose the day on which your passport was issued, as it appears on your passport under the Date of Issue field. The day on which the passport was issued is required to complete the application. In the Month field, choose the month in which your passport was issued, as it appears on your passport under the Date of Issue field. The month in which the passport was issued is required to complete the application. In the Year field, choose the year in which your passport was issued, as it appears on your passport under the Date of Issue field. The year in which the passport was issued is required to complete the application.
Issuance Date cannot be blank.
In the Day field, choose the day on which your passport expires, as it appears on your passport under the Expiration Date field. The day on which the passport expires is required to complete the application. In the Month field, choose the month in which your passport expires, as it appears on your passport under the Expiration Date field. The month in which the passport expires is required to complete the application. In the Year field, choose the year in which your passport expires, as it appears on your passport under the Expiration Date field. The year in which the passport expires is required to complete the application.
Expiration Date cannot be blank.

Identification Information

Choose the country of citizenship, as it appears on your passport. The country of citizenship is required to complete the application.
Country of Citizenship cannot be blank.
Enter the number on your identity document, other than a passport, issued by your country. The National Identification Number, if issued to you, is required to complete the application. If you do not have a National Identification Number, enter UNKNOWN.
National Identification Number cannot be blank.
Enter your personal identification number as it appears on your passport. The personal identification number starts with an English letter followed by 9 numbers. The Personal Identification Number is required to complete the application.
Personal Identification Number cannot be blank.
The Membership Number is exactly nine digits. It is labeled as Membership Number / PASSID  and can be found by logging into your GOES account.

Parents

In the Family Name field, enter your parent's family name. The family name is required to complete the application. If you do not know one or both of your parents, enter UNKNOWN.
Family Name cannot be blank.
In the First (Given) Name field, enter your parent's first (given) name. Do not include the middle name in this field. The first name is required to complete the application. If your parent has no first name, or if you do not know one or both of your parents, enter UNKNOWN.
First (Given) Name cannot be blank.
In the Family Name field, enter your parent's family name. The family name is required to complete the application. If you do not know one or both of your parents, enter UNKNOWN.
Family Name cannot be blank.
In the First (Given) Name field, enter your parent's first (given) name. Do not include the middle name in this field. The first name is required to complete the application. If your parent has no first name, or if you do not know one or both of your parents, enter UNKNOWN.
First (Given) Name cannot be blank.

Address Information

In the Address Line 1 field, enter the number and street of the location of your home address. Do not include the city and state in this field. Address line 1 is required to complete the application.
Address Line 1 cannot be blank.
In the Address Line 2 field, enter floor, building, or other, as appropriate. Do not include the city and state in this field. Address line 2 is optional to complete the application.
In the Apartment Number field, enter apartment, suite, unit, or other, as appropriate. Do not include the city and state in this field. Apartment number is optional to complete the application.
In the City field, enter the city, town, village, or hamlet. The city, town, village, or hamlet is required to complete the application.
City cannot be blank.
In the State/Province/Region field, enter the state, province, or region. The state/province/region is required to complete the application.
State/Province/Region cannot be blank.
In the Country field, choose the country. The country is required to complete the application.
Country cannot be blank.
Enter the email address at which you can be contacted. The email address is required to complete the application. If you do not have an email address, you may provide an alternative third-party email address belonging to a point of contact (e.g. a family member, friend or business associate.)
E-mail Address cannot be blank.
At least one telephone number is required to complete the application. If you do not have a telephone number, you may provide an alternative third-party telephone number belonging to a point of contact (e.g. a family member, friend, or business associate). In the Country Code field, enter the country code of the telephone number where you may be contacted. The country code is required to complete the application. In the Phone field, enter the telephone number where you may be contacted. The telephone number is required to complete the application.
Country Code + Phone cannot be blank.
At least one telephone number is required to complete the application. If you do not have a telephone number, you may provide an alternative third-party telephone number belonging to a point of contact (e.g. a family member, friend, or business associate). In the Type field, choose the type of the telephone number where you may be contacted. The telephone type is required to complete the application.
Telephone Type cannot be blank.
At least one telephone number is required to complete the application. If you do not have a telephone number, you may provide an alternative third-party telephone number belonging to a point of contact (e.g. a family member, friend, or business associate). In the Country Code field, enter the country code of the telephone number where you may be contacted. The country code is required to complete the application. In the Phone field, enter the telephone number where you may be contacted. The telephone number is required to complete the application.
Country Code + Phone cannot be blank.
At least one telephone number is required to complete the application. If you do not have a telephone number, you may provide an alternative third-party telephone number belonging to a point of contact (e.g. a family member, friend, or business associate). In the Type field, choose the type of the telephone number where you may be contacted. The telephone type is required to complete the application.
Telephone Type cannot be blank.
At least one telephone number is required to complete the application. If you do not have a telephone number, you may provide an alternative third-party telephone number belonging to a point of contact (e.g. a family member, friend, or business associate). In the Country Code field, enter the country code of the telephone number where you may be contacted. The country code is required to complete the application. In the Phone field, enter the telephone number where you may be contacted. The telephone number is required to complete the application.
Country Code + Phone cannot be blank.
At least one telephone number is required to complete the application. If you do not have a telephone number, you may provide an alternative third-party telephone number belonging to a point of contact (e.g. a family member, friend, or business associate). In the Type field, choose the type of the telephone number where you may be contacted. The telephone type is required to complete the application.
Telephone Type cannot be blank.

Emergency Contact

Enter your emergency point of contact who may be a person in or outside of the United States, e.g., a family member, friend, or business associate. In the Family Name field, enter your emergency contact's family name. You must complete this field to complete the application. If you have no emergency contact, enter UNKNOWN.
Family Name cannot be blank.
Enter your emergency point of contact who may be a person in or outside of the United States, e.g., a family member, friend, or business associate. In the First (Given) Name field, enter the emergency contact's first name. You must complete this field to complete the application. If you have no emergency contact (or your contact has only one name), enter UNKNOWN.
First (Given) Name cannot be blank.
Enter your emergency contact's email address. Email address is required to complete the application. You may also enter UNKNOWN.
E-mail Address cannot be blank.
In the Country Code field, enter the country code of your emergency contact's telephone number. The country code is required to complete the application. If you do not have an emergency contact telephone country code you may enter zeros. In the Phone field, enter your emergency contact's telephone number. The telephone number is required to complete the application. If you do not have an emergency contact telephone number you may enter zeros.
Country Code + Phone cannot be blank.
Disclaimer: Please ensure all information supplied is accurate and valid. Details must match your passport precisely, any information supplied incorrectly could invalidate your visa.