6ne20 i6

C o n su la r Electro n ic Application C enter - Prire Application

Online Nonimmigrant Visa Application (DS-160)

Application - Sensitive But UnelassifiedfSBU)

Wc do not need a printed copy of your application at any point during your interview process. Only print this
application if you want a copy for your own records. If you print your application, please keep it secure.

Photo Provided:

Confirmation Number:

Your Personal Copy -- Do Not Bring to Interview

Personal, Address, P h on e, and P a ssp o r t/T r a v e l D ocu m en t In form ation
Name Provided:

OWOIYA, TAOFIK ADISA

Full Name in Native Language:

DOES NOT APPLY

Other Names Used:

NO

Telecode Name Used:

NO

Sex:

M A LE

Marital Status:

SINGLE

Date of Birth:

02 AUGUST 1988

Place of Birth:

SURULERE, LAGOS, NIGERIA

Country/Region of Origin (Nationality):

NIGERIA

Do you hold or have you held any nationality other than the one
indicated above on nationality?

NO

Are you a permanent resident of a country/regfon other than your

country /region of origin (nationality) above?

NO

National Identification Number:

DOES NOT APPLY

U.S. Social Security Number:

DOES NOT APPLY

U.S. Taxpayer ID Number:

DOES NOT APPLY

Home Address:

15A OLAWALE DAUDU STREET

City:

SU R U LER E

State/Province:

LAG O S

Postal Zone/ZIP Code:

23401

Country/Region:

NIGERIA

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Consular Electronic Application Center - Print Application

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S a m e M a ilin g A d d r e s s ?

YES

P rim a r y P h o n e N u m b e r :

234706905S169

S e c o n d a ry P hone N u m b er:

D O E S N O T APPLY

W o rk P h o n e N u m b e r:

D O ES N O T APPLY

E m a il A d d r e s s :

t .o w a iy a @ h o t m a ii.c o m

P a ss p o rt/ T ra v e l D o c u m e n t T y p e :

REGU LAR

P a ss p o rt/ T ra v e i D o c u m e n t N u m b e r:

A07372427

P a ss p o rt B o o k N u m b er:

D O ES N O T APPLY

C o u n t r y / A u t h o r it y t h a t I s s u e d P a s s p o r t / T r a v e l D o c u m e n t :

N IG E R IA

C it y W h e r e I s s u e d :

IK O Y I

S t a t e / P r o v in c e W h e r e I s s u e d :

LAGOS

C o u n t r y / R e g io n W h e r e I s s u e d :

N IG E R IA

I s s u a n c e D a te :

15 A P R I L 2 0 1 6

E x p ir a t io n D a t e :

14 A P R I L 2 0 2 1

H a v e y o u e v e r l o s t a p a s s p o r t o r h a d o n e s t o le n ?

NO

T ravel In form ation

T h e L is t o f P u r p o s e s o f T r ip to t h e U . S .
P u r p o s e o f T r ip to t h e U . S . ( 1 ):

T E M P . B U S I N E S S P L E A S U R E V I S I T O R (B )

S p e c if y :

B U S IN E S S & TO U R IS M (TEM P O R A R Y V ISITO R )

(B 1/B 2 )

H a v e y o u m a d e s p e c ific t r a v e l p la n s ?

YES

P r o v i d e a c o m p l e t e it in e r a r y f o r y o u r t r a v e l to t h e U . S . :
D a t e o f A r r i v a l in U . S . :

28 S E P T E M B E R 2016

A r r i v a l C it y :

M O B ILE, A L A B A M A

D a te o f D e p a rtu r e fro m

U .S .:

11 O C T O B E R 2 0 1 6

A d d r e s s w h e r e y o u w ill s t a y In t h e U . S . :

9 0 0 W E S T 1 -6 5 S E R V I C E R O A D S O U T H

P e r s o n / E n t it y P a y in g f o r Y o u r T r ip ;

C O M P A N Y /O R G A N IZA TIO N

C o m p a n y / O r g a n i z a t i o n P a y in g f o r t h e T r i p :

T O M T IM E IN V E S T M E N T LIM ITE D

T e le p h o n e N u m b e r:

2348030719539

R e l a t i o n s h i p to Y o u :

M EM B ER /S P O N SO R O F S W B N -S O C IE T Y FO R TH E
W E L F A R E O F T H E B L I N D IN N I G E R I A

A d d r e s s o f C o m p a n y / O r g a n i z a t i o n P a y in g :

1 7 , K O L E O S H O A H M E D S T R E E T , L3M CA R O A D
IS H ER I O S H U N

C it y :

ISO LD

S t a t e / P r o v in c e :

LAG O S

P o stal Z o n e / Z IP C o d e :

23401

C o u n t r y / R e g io n :

N IG E R IA

A r e t h e r e o t h e r p e r s o n s t r a v e l i n g w ith y o u ?

YES

A r e y o u t r a v e l i n g a s p a r t o f a g r o u p o r o r g a n i z a t io n ?

YES

N a m e o f th e G r o u p :

S W B N - S O C I E T Y F O R T H E W E L F A R E O F T H E B L I N D IN
N IG E R IA

H a v e y o u e v e r b e e n in t h e U . S . ?

NO

H a v e y o u e v e r b e e n is s u e d a U . S . v i s a ?

NO

H a v e y o u e v e r b e e n r e f u s e d a U . S . V i s a , o r b e e n r e f u s e d a d m is s io n

NO

httpsjVbe3C.state.gov/GenNIVVcaTinion'printapp!!catic^.aspx?9NGAGM rOm CkOrOlZy% 2{hq1M 59!e3'i'3TVlf?Tx6K89Y F 6g%3d

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Consular Electronic Application Center - Print Application

to t h e U n it e d S t a t e s , o r w it h d r a w n y o u r a p p l i c a t io n f o r a d m is s io n a t
th e p o rt o f e n t ry ?
H a s a n y o n e e v e r f i l e d a n i m m i g r a n t p e t it io n o n y o u r b e h a l f w ith t h e

NO

U n it e d S t a t e s C it i z e n s h ip a n d I m m ig r a t io n S e r v i c e s ?

U.S. C ontact In form ation

C o n t a c t P e r s o n N a m e in th e U . S . :

L A R O S E , JIM M Y

O r g a n i z a t io n N a m e in t h e U . S . :

N A T IO N A L D E V E LO P M EN T IN STITU TE

R e l a t i o n s h i p to Y o u :

OTH ER

U .S . C o n t a c t A d d r e s s :

P O B O X 1840
LE X IN G T O N , S O U T H C A R O LIN A 29071

P hone N u m b er:

8002576670

E m a il A d d r e s s :

t e a m @ d e v e lo p m e n t .n e t

Fam ily In form ation

F a th e r 's S u r n a m e s :

O W O IY A

F a th e r 's G iv e n N a m e s :

SA K A R IY A U

F a t h e r ' s D a t e o f B ir t h :

05 A U G U S T 1958

I s y o u r f a t h e r in t h e U . S . ?

NO

M o t h e r 's S u r n a m e s :

A JIBO Y E

M o t h e r 's G i v e n N a m e s :

TA IY E

M o t h e r 's D a t e o f B ir t h :

01 O C T O B E R

I s y o u r m o t h e r in t h e U . S . ?

NO

D o y o u h a v e a n y i m m e d i a t e r e l a t i v e s , n o t in c lu d in a p a r e n t s In t h e

NO

1965

U .S .?
D o y o u h a v e a n y o t h e r r e l a t i v e s in t h e U n it e d S t a t e s ?

NO

W ork /E d u cation /T rain in g In form ation

P r i m a r y O c c u p a t io n :

STUDENT

P re s e n t E m p lo y e r o r S c h o o l N a m e :

U N IV ER S ITY O F LA G O S

A d d re ss:

AKO KA ROAD

C it y :

YABA

S t a t e / P r o v in c e :

LAG O S

P o s ta l Z o n e / Z ip C o d e ;

23401

C o u n t r y / R e g io n :

N IG ER IA

W o rk Phone N u m b e r:

2341733963

M o n t h ly S a l a r y in L o c a l C u r r e n c y ( if e m p l o y e d ) :

D O ES N O T APPLY

B r i e f ly D e s c r i b e y o u r D u t ie s :

STU D Y IN G M A S S CO M M U N IC A TIO N

W e r e y o u p r e v io u s ly e m p lo y e d ?

NO

H a v e y o u a t t e n d e d a n y e d u c a t io n a l i n s t it u t io n s a t a s e c o n d a r y l e v e l

YES

or above?
N a m e o f I n s t it u t io n ( 1 ) :

K I N G 'S C O L L E G E

A d d r e s s o f I n s t it u t io n :

3, C A T H O L I C M IS S IO N S T R E E T

C it y :

L A G O S ISLA N D

S t a t e / P r o v in c e :

LAG O S

P o stal Z o n e / Z IP C o d e :

23401

C o u n t r y / R e g io n :

N IG E R IA

C o u rs e o f S tu d y :

H IG H S C H O O L

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Consular Electronic Application Center - Print Application

Date of Attendance From:

18 SEPTEMBER 2006

Date of Attendance To:

19 JULY 2011

Do you belong to a clan or tribe?

YES

Clan or Tribe Name:

YQRUBA

Provide a List of Languages You Speak;

Language Name (1):

ENGLISH

Language Name (2):

YORUBA

Have you traveled to any countries/regions within the last five years? NO
Have you belonged to, contributed to, or worked for any professional, YES
social, or charitable organization?
Name of Organization (1):

SWBN-SOCIETY FOR THE WELFARE OF THE BUND IN

NIGERIA

Do you have any specialized skills or training, such as firearms,

explosives, nuclear, biological, or chemical experience?

NO

Have you ever served in the military?

NO

Have you ever served in, been a member of, or been involved with a NO
paramilitary unit, vigilante unit, rebel group, guerrilla group, or
insurgent organization?

S ecu rity and Background In form ation

Do you have a communicable disease of public health significance? (Communicable diseases of public
significance include chancroid, gonorrhea, granuloma inguinale, infectious leprosy, lymphogranuloma
venereum, infectious stage syphilis, active tuberculosis, and others diseases as determined by the Department
of Health and Human Services.)

NO

Do you have a mental or physical disorder that poses or is likely to pose a threat to the safety or welfare of
yourself or others?

NO

Are you or have you ever been a drug abuser or addict?

NO

Have you ever been arrested or convicted for any offense or crime, even though subject of a pardon, amnesty,
or other similar action?

NO

Have you ever violated, or engaged in a conspiracy to violate, any law relating to controlled substances?

NO

Are you coming to the United States to engage in prostitution or unlawful commercialized vice or have you
been engaged in prostitution or procuring prostitutes within the past 10 years?

NO

Have you ever been involved in, or do you seek to engage in, money laundering?

NO

Have you ever committed or conspired to commit a human trafficking offense in the United States or outside
the United States?

NO

Are you the spouse, son, or daughter of an individual who has committed or conspired to commit a human
trafficking offense in the United States or outside the United States and have you within the last five years,
knowingly benefited from the trafficking activities?

NO

Have you knowingly aided, abetted, assisted or colluded with an individual who has committed or conspired to
commit a severe human trafficking offense in the United States or outside the United States?

NO

Do you seek to engage in espionage, sabotage, export control violations, or any other illegal activity while in
the United States?

NO

Do you seek to engage in terrorist activities while in the United States or have you ever engaged in terrorist
activities?

NO

Have you ever or do you intend to provide financial assistance or other support to terrorists or terrorist
organizations?

NO

Are you a member or representative of a terrorist organization?

NO

Have you ever ordered, incited, committed, assisted, or otherwise participated in genocide?

NO

Have you ever committed, ordered, incited, assisted, or otherwise participated in torture?

NO

Have you committed, ordered, incited, assisted, or otherwise participated in extrajudicial killings, political
killings, or other acts of violence?

NO

Have you ever engaged in the recruitment or the use of the child soldiers?

NO

Have you, while serving as a government official, been responsible for or directly carried out, at any time,

NO

https://ceac.state.gov/GenNlV/common/printappUcation.aspx79NGAGMnOmCkOnOLZy%2fhq1MSK3v3TViftTx6KKYF6g%3d

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Constiar Electronic Application Center - Prirt Application

particularly severe violations of religious freedom?

Have you ever been directly involved in the establishment or enforcement of the population controls forcing a
woman to undergo an abortion against her free choice or a man or a woman to undergo sterilization against his
or her free will?

NO

Have you ever been directly involved in the coercive transplantation of human organs or bodily tissue?

NO

Have you ever sought to obtain or assist others to obtain a visa, entry into the United States, or any other
United States immigration benefit by fraud or willful misrepresentation or other unlawful means?

NO

Have you ever withheld custody of a U.S. citizen child outside the United States from a person granted legal
custody by a U.S. court?

NO

Have you voted in the United States in violation of any law or regulation?

NO

Have you ever renounced United States citizenship for the purpose of avoiding taxation?

NO

Location Information
Location where you will be submitting your application
Current Location:

LAGOS, NIGERIA

P reparer o f A pplication
Did anyone assist you in filling out this application?

YES

Preparer Surnames:

QBQ

Preparer Given Names:

UGQCHUKWU IHECHUKWU

Organization Name:

SWBN

Street Address:

33, LIADI DISU STREET

ISHERI OSHUN

City:

ISOLO

S t a t e / P r o w in c e :

LAGOS

Postal Zone/ZIP Code:

23401

Country/Region:

NIGERIA

Relationship to You:

MY COLLEAGUE AT SWBN-SOCIETY FOR THE

WELFARE OF THE BLIND IN NIGERIA

Your Personal Copy - Do Not Bring to Interview

You electronically signed your application on 16-3un-20I6 11:15:49 (GMT-05:00). You were required to electronically sign your
application yourself, unless otherwise exempt by regulation, even if the application was prepared by someone other than
yourseif. Your electronic signature certifies that you have read and understood the questions in this application and that your
answers are true and correct to the best of your knowledge and belief. The submission of an application containing any false or
misleading statements may result in the permanent refusal of a visa or the denial of entry into the United States. All declarations
made in this application are unsworn declarations made under penalty of perjury. (28 U.S.C. 1746).
You certified that you understand that you are required to submit your visa to the United States Immigration Officer at the port
where you apply to enter the United States, and that possession of the visa does not entitle you to enter the United States if,
upon your arrival, you are found to be inadmissible under U.S. immigration laws. You certified that you understand that any
willfully false or misleading statement or willful concealment of a material fact made by you within the application may subject
you to permanent exclusion from the United States and, if you are admitted to the United States, may subject you to criminal
prosecution and/or deportation.
The information that you have provided in your application and other information submitted with your application may be
accessible to other government agencies having statutory or other lawful authority to use such information, including for law
enforcement and immigration law enforcement purposes. If fingerprints are collected as part of your application process, they
may be used for the purpose of comparing them to other fingerprints in the FBI's Next Generation Identification (NGI) fingerprint
system or its successor systems (including civil, criminal, and latent fingerprint repositories). The photograph that you provide
with your application may be used for employment verification or other U.S. law purposes.

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