8/11/2020 Consular Electronic Application Center - Print Application

Online Nonimmigrant Visa Application (DS-160)

Application - Sensitive But Unclassified(SBU)

We 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, Phone, and Passport/Travel Document Information
Name Provided: CHUQUICAHUANA FLORES, JUANA VICTORIA

Full Name in Native Language: DOES NOT APPLY

Other Names Used: NO

Telecode Name Used: NO

Sex: FEMALE

Marital Status: MARRIED

Date of Birth: 04 APRIL 1962

Place of Birth: LIMA, PERU

Country/Region of Origin (Nationality): PERU

Do you hold or have you held any nationality other than the one NO
indicated above on nationality?

Are you a permanent resident of a country/region other than your NO

country/region of origin (nationality) above?

National Identification Number: 21822849

U.S. Social Security Number: DOES NOT APPLY

U.S. Taxpayer ID Number: DOES NOT APPLY

Home Address: JR FRANCISCO VALLEJO 477

URB PAMPLONA BAJA

City: SJM

State/Province: LIMA

Postal Zone/ZIP Code: DOES NOT APPLY

Country/Region: PERU

Same Mailing Address? YES

Primary Phone Number: 014502954

Secondary Phone Number: 970537615

Work Phone Number: DOES NOT APPLY

Your Personal Copy -- Do Not Bring to Interview

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Your Personal Copy -- Do Not Bring to Interview

Do you have any additional phone numbers? NO

Email Address: JUANA.CH.FLORES2020@GMAIL.COM

Do you have any additional email addresses? NO

Do you have a social media presence?

Social Media Platform: (1): NONE

Social Media Identifier:

Do you have any additional social media presence? NO

Passport/Travel Document Type: REGULAR

Passport/Travel Document Number: 119212286

Passport Book Number: DOES NOT APPLY

Country/Authority that Issued Passport/Travel Document: PERU

City Where Issued: LIMA

Country/Region Where Issued: PERU

Issuance Date: 24 AUGUST 2020

Expiration Date: 24 AUGUST 2025

Have you ever lost a passport or had one stolen? NO

Travel Information
The List of Purposes of Trip to the U.S.

Purpose of Trip to the U.S. (1): TEMP. BUSINESS PLEASURE VISITOR (B)

Specify: BUSINESS & TOURISM (TEMPORARY VISITOR)

(B1/B2)

Have you made specific travel plans? NO

Intended Date of Arrival: FEBRUARY 2021

Intended Length of Stay in U.S.: 10 DAY(S)

Address where you will stay in the U.S.: 1111 S ROYAL POINCIANA BLVD

Person/Entity Paying for Your Trip: SELF

Are there other persons traveling with you? YES

Are you traveling as part of a group or organization? YES

Name of the Group: GRUPO FAMILIAR

Have you ever been in the U.S.? NO

Have you ever been issued a U.S. visa? NO

Have you ever been refused a U.S. Visa, or been refused admission to NO
the United States, or withdrawn your application for admission at the
port of entry?

Has anyone ever filed an immigrant petition on your behalf with the NO
United States Citizenship and Immigration Services?

U.S. Contact Information

Contact Person Name in the U.S.: DO NOT KNOW

Organization Name in the U.S.: HOLIDAY INN MIAMI

Relationship to You: OTHER

U.S. Contact Address: 1111 S ROYAL POINCIANA BLVD

MIAMI, FLORIDA 33166

Phone Number: 3058851941

Email Address: DOES NOT APPLY

Family Information
Father's Surnames: CHUQUICAHUANA ESPINOZA

Your Personal Copy -- Do Not Bring to Interview

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Your Personal Copy -- Do Not Bring to Interview

Father's Given Names: PIO

Father's Date of Birth: DO NOT KNOW

Is your father in the U.S.? NO

Mother's Surnames: FLORES DE CAMPOS

Mother's Given Names: AQUELINA

Mother's Date of Birth: 13 JUNE 1943

Is your mother in the U.S.? NO

Do you have any immediate relatives, not including parents in the U.S.? NO

Do you have any other relatives in the United States? NO

Spouse's Full Name: GONZALES NAPA, LUIS FELIX

Spouse's Date of Birth: 22 NOVEMBER 1959

Spouse's Country/Region of Origin (Nationality): PERU

Spouse's City of Birth: ICA

Spouse's Country/Region of Birth: PERU

Spouse’s Address: SAME AS HOME ADDRESS

Work/Education/Training Information
Primary Occupation: OTHER

Specify Other: VENTAS AL POR MENOR DE ALIMENT

OS EN COMERCIO 2000 ARRIENDO
UNA CASA QUE ESTA UBICADA EN
CHINCHA MZ Q LT 14 ASENT MIGUE
L GRAU PUEBLO NUEVO 5000

Present Employer or School Name: RUC 10218228491

Address: JR FRANCISCO VALLEJO 477 PAMPLONA BAJA

City: SJM

State/Province: LIMA

Postal Zone/Zip Code: DOES NOT APPLY

Country/Region: PERU

Work Phone Number: 970537615

Monthly Salary in Local Currency (if employed): 2500

Briefly Describe your Duties: VENTA AL POR MENOR DE ALIMENTO

S EN COMERCIO 2000 ARRIENDO U
NA CASA QUE SE ENCUENTRA UBICA
DA EN CHINCHA DIRECCION MZ Q L
T 14 ASENT MIGUEL GRAU PUEBLO
NUEVO 500

Were you previously employed? NO

Have you attended any educational institutions at a secondary level or NO

above?

Do you belong to a clan or tribe? NO

Provide a List of Languages You Speak:

Language Name (1): CASTELLANO

Have you traveled to any countries/regions within the last five years? NO

Have you belonged to, contributed to, or worked for any professional, NO
social, or charitable organization?

Do you have any specialized skills or training, such as firearms, NO

explosives, nuclear, biological, or chemical experience?

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?

Your Personal Copy -- Do Not Bring to Interview

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Your Personal Copy -- Do Not Bring to Interview

Security and Background Information
Do you have a communicable disease of public health significance? (Communicable diseases of public significance NO
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.)

Do you have a mental or physical disorder that poses or is likely to pose a threat to the safety or welfare of NO
yourself or others?

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 NO
other similar action?

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 NO
engaged in prostitution or procuring prostitutes within the past 10 years?

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 NO
United States?

Are you the spouse, son, or daughter of an individual who has committed or conspired to commit a human NO
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?

Have you knowingly aided, abetted, assisted or colluded with an individual who has committed or conspired to NO
commit a severe human trafficking offense in the United States or outside the United States?

Do you seek to engage in espionage, sabotage, export control violations, or any other illegal activity while in the NO
United States?

Do you seek to engage in terrorist activities while in the United States or have you ever engaged in terrorist NO
activities?

Have you ever or do you intend to provide financial assistance or other support to terrorists or terrorist NO
organizations?

Are you a member or representative of a terrorist organization? NO

Are you the spouse, son, or daughter of an individual who has engaged in terrorist activity, including providing NO
financial assistance or other support to terrorists or terrorist organizations, in the last five years?

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, NO
or other acts of violence?

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
particularly severe violations of religious freedom?

Have you ever been directly involved in the establishment or enforcement of the population controls forcing a NO
woman to undergo an abortion against her free choice or a man or a woman to undergo sterilization against his or
her free will?

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 NO
States immigration benefit by fraud or willful misrepresentation or other unlawful means?

Have you ever been removed or deported from any country? NO

Have you ever withheld custody of a U.S. citizen child outside the United States from a person granted legal NO
custody by a U.S. court?

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: LIMA, PERU

Preparer of Application
Did anyone assist you in filling out this application? NO

Your Personal Copy -- Do Not Bring to Interview

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Usted firmó su solicitud de manera electrónica el 08-Nov-2020 02:57:38 (GMT-05:00). Se le requirió firmar su solicitud
personalmente y de manera electrónica al menos que por reglamento quede exento de ello y aún si el formulario fue elaborado a su
nombre por alguien más. Su firma electrónica certifica que usted ha leído y entendido las preguntas en su solicitud de Visa de No-
Inmigrante y que además todas sus respuestas son verdaderas y realizadas a su mejor entender y convicción. La entrega de una
solicitud conteniendo declaraciones falsas y engañosas pueden resultar en la negativa permanente de una visa para entrar a los
Estados Unidos de Norteamérica. Todas las declaraciones hechas en esta solicitud no están sujetas a juramento pero deben ser
hechas bajo protesta de decir verdad. (28 U.S.C. 1746).

La información que usted ha proporcionado en su solicitud y alguna otra enviada junto con ésta, puede ser puesta a disposición de
otras agencias del gobierno con el derecho y la autoridad legal que les confiere para usar dicha información, incluso para propósitos
del órden público y leyes de inmigración. Si se obtienen huellas dactilares como parte de su proceso de solicitud, éstas pueden ser
usadas con el propósito de compararlas con otras huellas dactilares en el Sistema de Identificación de Siguiente Generación (Next
Generation Identification System) NGI por sus siglas en inglés, de la Oficina Federal de Investigación (Federal Bureau of
Investigation - FBI por sus siglas en inglés) o por sus sistemas subsecuentes (incluyendo civiles, criminales y archivos existentes de
huellas dactilares). La fotografía que proporcione junto con su solicitud puede ser utilizada para verificación de empleo u otros
propósitos competentes a la legislación de los Estados Unidos de Norteamérica.

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