NAME PROVIDED FULL NAME IN NATIVE LANGUAGE OTHER NAMES USED SEX MARITAL STATUS DATE OF BIRTH PLACE OF BIRTH NATIONALITY OTHER NATIONALITIES NATIONAL IDENTIFICATION NUMBER HOME ADDRESS CITY STATE/PROVINCE POSTAL ZONE/ZIP CODE COUNTRY SAME MAILING ADDRESS? HOME PHONE NUMBER WORK PHONE NUMBER WORK FAX NUMBER MOBILE/CELL PHONE NUMBER EMAIL ADDRESS PASSPORT NUMBER PASSPORT BOOK NUMBER COUNTRY/AUTHORITY THAT ISSUED PASSPORT CITY WHERE ISSUED COUNTRY WHERE ISSUED ISSUANCE DATE EXPIRATION DATE HAVE YOU EVER LOST A PASSPORT OR HAD ONE STOLEN? TRAVEL INFORMATION PRINCIPAL APPLICANT? PURPOSE OF YOUR TRIP TO THE US INTENDED DATE OF ARRIVAL INTENDED LENGTH OF STAY IN US ADDRESS WHERE U WILL STAY IN THE US PERSON/ENTITY PAYING FOR YOUR TRIP OTHER PERSONS TRAVELLING WITH YOU Are you travelling as part of a group or org?
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NAME PROVIDEDFULL NAME IN NATIVE LANGUAGEOTHER NAMES USEDSEXMARITAL STATUSDATE OF BIRTH PLACE OF BIRTHNATIONALITYOTHER NATIONALITIESNATIONAL IDENTIFICATION NUMBERHOME ADDRESSCITYSTATE/PROVINCEPOSTAL ZONE/ZIP CODECOUNTRYSAME MAILING ADDRESS?HOME PHONE NUMBERWORK PHONE NUMBERWORK FAX NUMBERMOBILE/CELL PHONE NUMBEREMAIL ADDRESSPASSPORT NUMBERPASSPORT BOOK NUMBERCOUNTRY/AUTHORITY THAT ISSUED PASSPORTCITY WHERE ISSUEDCOUNTRY WHERE ISSUEDISSUANCE DATEEXPIRATION DATEHAVE YOU EVER LOST A PASSPORT OR HAD ONE STOLEN?
TRAVEL INFORMATIONPRINCIPAL APPLICANT?PURPOSE OF YOUR TRIP TO THE USINTENDED DATE OF ARRIVALINTENDED LENGTH OF STAY IN USADDRESS WHERE U WILL STAY IN THE USPERSON/ENTITY PAYING FOR YOUR TRIPOTHER PERSONS TRAVELLING WITH YOU
Are you travelling as part of a group or org?NAMERELATIONSHIP TO YOU
HAVE YOU EVER BEEN TO THE US?HAVE YOU EVER BEEN ISSUED A US VISA?
HAVE YOU EVER BEEN REFUSED A US VISA.....?
US CONTACT INFORMATIONCONTACT PERSON NAME IN THE USORGANIZATION NAME IN THE USRELATIONSHIP TO YOUUS CONTACT ADDRESSPHONE NUMBEREMAIL ADDRESS
FAMILY INFORMATIONFATHER’S SURNAMESFATHER’S GIVEN NAMESFATHER’S DATE OF BIRTHIS YOUR FATHER IN THE US?MOTHER’S SURNAMESMOTHER’S GIVEN NAMESMOTHER’S DATE OF BIRTHIS YOUR MOTHER IN THE US?DO YOU HAVE ANY IMMEDIATE RELATIVES, NOT INCLUDING PARENTS IN THE US?
RELATIVE NAMERELATIONSHIP TO YOUSTATUS
WORK/EDUCATION/TRAINING INFORMATIONPRIMARY OCCUPATIONPRESENT EMPLOYER OR SCHOOL NAMEADDRESSCITYSTATE/PROVINCEPOSTAL CODE/ZIP CODECOUNTRYMONTHLY SALARY IN LOCAL CURRENCYBRIEFLY DISCRIBE YOUR DUTIES
SECURITY AND BACKGROUND INFORMATIONLOCATION INFORMATIONCURRENT LOCATION
PREPARER OF INFORMATIONDid anyone assist you in filling up this application?Preparer SurnamesPreparer Given NamesOrganization NameStreet AddressCityState/ProvincePostal Zone/Zip CodeCountry Relationship to you
NAME PROVIDED Querol, Ma. Teresa PasinosFULL NAME IN NATIVE LANGUAGE does not applyOTHER NAMES USED noSEX femaleMARITAL STATUS singleDATE OF BIRTH October 3, 1977PLACE OF BIRTH Tuguegarao CityNATIONALITY filipinoOTHER NATIONALITIES noNATIONAL IDENTIFICATION NUMBER does not applyHOME ADDRESS 27 Mabini StreetCITY Tuguegarao CitySTATE/PROVINCE CagayanPOSTAL ZONE/ZIP CODE 3500COUNTRY PhilippinesSAME MAILING ADDRESS? yesHOME PHONE NUMBER +63788440846WORK PHONE NUMBER +639274592801WORK FAX NUMBER +63788440846MOBILE/CELL PHONE NUMBER +639175785688 / +639228468486EMAIL ADDRESS [email protected] NUMBER XX2884800PASSPORT BOOK NUMBER does not applyCOUNTRY/AUTHORITY THAT ISSUED PASSPORT Philippines/DFA Consular Office CITY WHERE ISSUED TuguegaraoCOUNTRY WHERE ISSUED PhilippinesISSUANCE DATE 27 January 2009EXPIRATION DATE 26 January 2014HAVE YOU EVER LOST A PASSPORT OR HAD ONE STOLEN? Yes
TRAVEL INFORMATIONPRINCIPAL APPLICANT? YesPURPOSE OF YOUR TRIP TO THE US personal travelINTENDED DATE OF ARRIVAL JuneINTENDED LENGTH OF STAY IN US 3 weeksADDRESS WHERE U WILL STAY IN THE US 100 Woodmere Avenue
Mays Landing, New Jersey 08330PERSON/ENTITY PAYING FOR YOUR TRIP SelfOTHER PERSONS TRAVELLING WITH YOU
Are you travelling as part of a group or org? NoNAME Maricel Judith Querol/Dorotea Cagurangan
Kathleen C. BautistaRELATIONSHIP TO YOU Sister/Aunt/Bestfriend
HAVE YOU EVER BEEN TO THE US? YesHAVE YOU EVER BEEN ISSUED A US VISA? YesHAVE YOU EVER BEEN REFUSED A US VISA.....? Yes
US CONTACT INFORMATIONCONTACT PERSON NAME IN THE US Mary Antoniette Querol SalvatierraORGANIZATION NAME IN THE US Meadowview Nursing HomeRELATIONSHIP TO YOU SisterUS CONTACT ADDRESS 100 Woodmere Avenue
Mays Landing, New Jersey 08330PHONE NUMBER +15168089366EMAIL ADDRESS [email protected]
FAMILY INFORMATIONFATHER’S SURNAMES QuerolFATHER’S GIVEN NAMES CelestinoFATHER’S DATE OF BIRTH October 14, 1938IS YOUR FATHER IN THE US? NoMOTHER’S SURNAMES QuerolMOTHER’S GIVEN NAMES SaludMOTHER’S DATE OF BIRTH October 27, 1941IS YOUR MOTHER IN THE US? NoDO YOU HAVE ANY IMMEDIATE RELATIVES, NOT INCLUDING PARENTS IN THE US? Yes
RELATIVE NAME Mary Antoniette Querol SalvatierraRELATIONSHIP TO YOU SisterSTATUS Immigrant
WORK/EDUCATION/TRAINING INFORMATIONPRIMARY OCCUPATION BusinessPRESENT EMPLOYER OR SCHOOL NAME Querol PawnshopADDRESS 27a Mabini StreetCITY Tuguegarao CitySTATE/PROVINCE CagayanPOSTAL CODE/ZIP CODE 3500COUNTRY PhilippinesMONTHLY SALARY IN LOCAL CURRENCY P45,000.00 – P65,000.00BRIEFLY DISCRIBE YOUR DUTIES
I do the daily transactions in my pawnshop with my assistant. Such duties are appraisal of pawned items, pawning, renewal and redemption transactions. The pawnshop is an agent of western union and we also have daily receive and send transactions. I personally do the register of loans extended and loans paid required by the Bangko Sentral ng Pilipinas and also the financial statements.
I personally attend seminars by the Bangko Sentral ng Pilipinas and the Chamber of Pawnbrokers of the Philippines, Incorporated of which I am a member. I do the renewal of our Mayor’s permit, Bangko Sentral Pawnshop Registration and Department of Trade and Industry permit.
SECURITY AND BACKGROUND INFORMATIONLOCATION INFORMATIONCURRENT LOCATION 27 Mabini Street Tuguegarao City
PREPARER OF INFORMATIONDid anyone assist you in filling up this application? NoPreparer SurnamesPreparer Given NamesOrganization NameStreet AddressCityState/ProvincePostal Zone/Zip CodeCountry Relationship to you
NAME PROVIDED QUEROL, MARICEL JUDITH PASINOSFULL NAME IN NATIVE LANGUAGEOTHER NAMES USEDSEX FEMALEMARITAL STATUS SINGLEDATE OF BIRTH OCTOBER 28, 1969PLACE OF BIRTH TUGUEGARAO CITYNATIONALITY FILIPINOOTHER NATIONALITIESNATIONAL IDENTIFICATION NUMBERHOME ADDRESS 27 MABINI STREETCITY TUGUEGARAO STATE/PROVINCE CAGAYANPOSTAL ZONE/ZIP CODE 3500COUNTRY PHILIPPINESSAME MAILING ADDRESS? YESHOME PHONE NUMBER +63788440846WORK PHONE NUMBER +63788440846WORK FAX NUMBER +63788440846MOBILE/CELL PHONE NUMBER +639175785126/ +639331658203EMAIL ADDRESS [email protected] NUMBER XX2886940PASSPORT BOOK NUMBERCOUNTRY/AUTHORITY THAT ISSUED PASSPORT PHILIPPINES/DFA CONSULAR OFFICE CITY WHERE ISSUED TUGUEGARAOCOUNTRY WHERE ISSUED PHILIPPINESISSUANCE DATE 27 JANUARY 2009EXPIRATION DATE 26 JANUARY 2014HAVE YOU EVER LOST A PASSPORT OR HAD ONE STOLEN? NO
TRAVEL INFORMATIONPRINCIPAL APPLICANT? YESPURPOSE OF YOUR TRIP TO THE US PERSONAL TRAVELINTENDED DATE OF ARRIVAL JUNEINTENDED LENGTH OF STAY IN US 3 WEEKSADDRESS WHERE U WILL STAY IN THE US 100 WOODMERE AVENUE
MAYS LANDING NEW JERSEY 08330PERSON/ENTITY PAYING FOR YOUR TRIP MYSELFOTHER PERSONS TRAVELLING WITH YOU
Are you travelling as part of a group or org?NAME MA. TERESA P. QUEROL
DOROTEA P. CAGURANGANKATHLEEN BAUTISTA
RELATIONSHIP TO YOU SISTER/AUNT/FRIENDHAVE YOU EVER BEEN TO THE US? NOHAVE YOU EVER BEEN ISSUED A US VISA? NOHAVE YOU EVER BEEN REFUSED A US VISA.....? YES
US CONTACT INFORMATIONCONTACT PERSON NAME IN THE US MARY ANTONIETTE Q. SALVATIERRAORGANIZATION NAME IN THE US MEADOWVIEW NURSING HOMERELATIONSHIP TO YOU SISTERUS CONTACT ADDRESS 100 WOODMERE AVENUE
MAYS LANDING, NEW JERSEY 08330PHONE NUMBER +15168089366EMAIL ADDRESS [email protected]
FAMILY INFORMATIONFATHER’S SURNAMES QUEROLFATHER’S GIVEN NAMES CELESTINOFATHER’S DATE OF BIRTH OCTOBER 14, 1938IS YOUR FATHER IN THE US? NOMOTHER’S SURNAMES QUEROLMOTHER’S GIVEN NAMES SALUDMOTHER’S DATE OF BIRTH OCTOBER 27, 1941IS YOUR MOTHER IN THE US? NODO YOU HAVE ANY IMMEDIATE RELATIVES, NOT INCLUDING PARENTS IN THE US?
RELATIVE NAME MARY ANTONIETTE Q. SALVATIERRARELATIONSHIP TO YOU SISTERSTATUS IMMIGRANT
WORK/EDUCATION/TRAINING INFORMATIONPRIMARY OCCUPATION DENTIST/ORTHODONTICSPRESENT EMPLOYER OR SCHOOL NAME QUEROL DENTAL CLINICADDRESS 27 MABINI STREETCITY TUGUEGARAOSTATE/PROVINCE CAGAYANPOSTAL CODE/ZIP CODE 3500COUNTRY PHILIPPINESMONTHLY SALARY IN LOCAL CURRENCY P 50,000.00 – 75,000.00BRIEFLY DISCRIBE YOUR DUTIES
I render dental services such as oral prophylaxis, restoration of tooth cavities, extraction of various teeth, construction of dental prosthesis for lost teeth, prescribes medications for the
treatment of oral diseases and orthodontic treatment for the prevention and/or correction of malposed teeth.
I participate in dental mission for free oral health services and education in underprivileged areas and I also am the District coordinator for Region 2 of the Philippine Dental Association.
SECURITY AND BACKGROUND INFORMATIONLOCATION INFORMATIONCURRENT LOCATION TUGUEGARAO CITY
PREPARER OF INFORMATIONDid anyone assist you in filling up this application?Preparer SurnamesPreparer Given NamesOrganization NameStreet AddressCityState/ProvincePostal Zone/Zip CodeCountry Relationship to you
NAME PROVIDED CAGURANGAN, DOROTEA PASINOSFULL NAME IN NATIVE LANGUAGEOTHER NAMES USEDSEX FEMALEMARITAL STATUS MARRIEDDATE OF BIRTH FEBRUARY 6, 1951PLACE OF BIRTH TUGUEGARAO CITYNATIONALITY FILIPINOOTHER NATIONALITIESNATIONAL IDENTIFICATION NUMBERHOME ADDRESS 4 BACUD STREET UGAC NORTECITY TUGUEGARAOSTATE/PROVINCE CAGAYANPOSTAL ZONE/ZIP CODE 3500COUNTRY PHILIPPINESSAME MAILING ADDRESS? YESHOME PHONE NUMBER +63788805423WORK PHONE NUMBER +63783049432/+63783040799WORK FAX NUMBERMOBILE/CELL PHONE NUMBER +639224090761EMAIL ADDRESS [email protected] NUMBER XX5235802PASSPORT BOOK NUMBERCOUNTRY/AUTHORITY THAT ISSUED PASSPORT PHILIPPINES/DFA CONSULAR OFFICECITY WHERE ISSUED TUGUEGARAOCOUNTRY WHERE ISSUED PHILIPPINESISSUANCE DATE 28 JANUARY 2010EXPIRATION DATE 27 JANUARY 2015HAVE YOU EVER LOST A PASSPORT OR HAD ONE STOLEN? NO
TRAVEL INFORMATIONPRINCIPAL APPLICANT? YESPURPOSE OF YOUR TRIP TO THE US PERSONAL TRAVELINTENDED DATE OF ARRIVAL JUNEINTENDED LENGTH OF STAY IN US 3 WEEKSADDRESS WHERE U WILL STAY IN THE US 100 WOODMERE AVENUE
MAYS LANDING, NEW JERSEY 08225PERSON/ENTITY PAYING FOR YOUR TRIP SELFOTHER PERSONS TRAVELLING WITH YOU
Are you travelling as part of a group or org? NONAME MARICEL JUDITH P. QUEROL
MA. TERESA P. QUEROLKATHLEEN C. BAUTISTA
RELATIONSHIP TO YOU NIECES/FRIEND OF MY NIECEHAVE YOU EVER BEEN TO THE US? NOHAVE YOU EVER BEEN ISSUED A US VISA? NOHAVE YOU EVER BEEN REFUSED A US VISA.....? NO
US CONTACT INFORMATIONCONTACT PERSON NAME IN THE US MARY ANTONIETTE Q. SALVATIERRAORGANIZATION NAME IN THE US MEADOWVIEW NURSING HOMERELATIONSHIP TO YOU NIECEUS CONTACT ADDRESS 100 WOODMERE AVENUE
MAYS LANDING, NEW JERSEY 08225PHONE NUMBER +15168089366EMAIL ADDRESS [email protected]
FAMILY INFORMATIONFATHER’S SURNAMES PASINOSFATHER’S GIVEN NAMES MAXIMIANOFATHER’S DATE OF BIRTH MAY 29, 1916IS YOUR FATHER IN THE US? NO (DECEASED)MOTHER’S SURNAMES PASINOSMOTHER’S GIVEN NAMES MARIAMOTHER’S DATE OF BIRTH APRIL 25, 1914IS YOUR MOTHER IN THE US? NO (DECEASED)DO YOU HAVE ANY IMMEDIATE RELATIVES, NOT INCLUDING PARENTS IN THE US?
RELATIVE NAME VIOLETA P. GUEVARRA/BENICIA P. LOPEZRELATIONSHIP TO YOU SISTERSTATUS CITIZEN
WORK/EDUCATION/TRAINING INFORMATIONPRIMARY OCCUPATION ASSOCIATE PROFESSORPRESENT EMPLOYER OR SCHOOL NAME CAGAYAN STATE UNIVERSITYADDRESS CARIGCITY TUGUEGARAOSTATE/PROVINCE CAGAYANPOSTAL CODE/ZIP CODE 3500COUNTRY PHILIPPINESMONTHLY SALARY IN LOCAL CURRENCY P 29,088.00BRIEFLY DISCRIBE YOUR DUTIES I teach Social Science subjects in the College
of Engineering and also teach Professional subjects in the College of Technology.
SECURITY AND BACKGROUND INFORMATIONLOCATION INFORMATIONCURRENT LOCATION Tuguegarao City
PREPARER OF INFORMATIONDid anyone assist you in filling up this application?Preparer SurnamesPreparer Given NamesOrganization NameStreet AddressCityState/ProvincePostal Zone/Zip CodeCountry Relationship to you
NAME PROVIDED BAUTISTA, KATHLEEN CAPILIFULL NAME IN NATIVE LANGUAGEOTHER NAMES USEDSEX FEMALEMARITAL STATUS SINGLEDATE OF BIRTH JUNE 7, 1977PLACE OF BIRTH AMULUNG, CAGAYANNATIONALITY FILIPINOOTHER NATIONALITIESNATIONAL IDENTIFICATION NUMBERHOME ADDRESS 1 MAYA STREET SAN GABRIEL VILLAGECITY TUGUEGARAOSTATE/PROVINCE CAGAYANPOSTAL ZONE/ZIP CODE 3500COUNTRY PHILIPPINESSAME MAILING ADDRESS? YESHOME PHONE NUMBER NAWORK PHONE NUMBER +63783041790WORK FAX NUMBER NAMOBILE/CELL PHONE NUMBER +639178606677EMAIL ADDRESS [email protected] NUMBER XX0573870PASSPORT BOOK NUMBERCOUNTRY/AUTHORITY THAT ISSUED PASSPORT PHILIPPINES/DFA CONSULAR OFFICECITY WHERE ISSUED TUGUEGARAOCOUNTRY WHERE ISSUED PHILIPPINESISSUANCE DATE 20 FEBRUARY 2008EXPIRATION DATE 19 FEBRUARY 2013HAVE YOU EVER LOST A PASSPORT OR HAD ONE STOLEN? NO
TRAVEL INFORMATIONPRINCIPAL APPLICANT? YESPURPOSE OF YOUR TRIP TO THE US PERSONAL TRAVELINTENDED DATE OF ARRIVAL JUNEINTENDED LENGTH OF STAY IN US 3 WEEKSADDRESS WHERE U WILL STAY IN THE US 100 WOODMERE AVENUE
MAYS LANDING, NEW JERSEY 08225PERSON/ENTITY PAYING FOR YOUR TRIP SELFOTHER PERSONS TRAVELLING WITH YOU
Are you travelling as part of a group or org? NONAME MA. TERESA P. QUEROL
MARICEL JUDITH P. QUEROLDOROTEA P. CAGURANGAN
RELATIONSHIP TO YOU FRIENDS/AUNT OF MY FRIENDSHAVE YOU EVER BEEN TO THE US? NOHAVE YOU EVER BEEN ISSUED A US VISA? NOHAVE YOU EVER BEEN REFUSED A US VISA.....? NO
US CONTACT INFORMATIONCONTACT PERSON NAME IN THE US MARY ANTONIETTE P. QUEROLORGANIZATION NAME IN THE US MEADOWVIEW NURSING HOMERELATIONSHIP TO YOU SISTER OF MY FRIENDUS CONTACT ADDRESS 100 WOODMERE AVENUE
MAYS LANDING, NEW JERSEY 08225PHONE NUMBER +15168089366EMAIL ADDRESS [email protected]
FAMILY INFORMATIONFATHER’S SURNAMES BAUTISTAFATHER’S GIVEN NAMES FELICIANO JR.FATHER’S DATE OF BIRTH APRIL 2, 1954IS YOUR FATHER IN THE US? NO (DECEASED)MOTHER’S SURNAMES CAPILI-BAUTISTAMOTHER’S GIVEN NAMES MAGDALENAMOTHER’S DATE OF BIRTH MAY 25, 1952IS YOUR MOTHER IN THE US? NODO YOU HAVE ANY IMMEDIATE RELATIVES, NOT INCLUDING PARENTS IN THE US? NO
RELATIVE NAMERELATIONSHIP TO YOUSTATUS
WORK/EDUCATION/TRAINING INFORMATIONPRIMARY OCCUPATION GOVERNMENT EMPLOYEE – CPA/LAWYERPRESENT EMPLOYER OR SCHOOL NAME COMMISSION ON AUDIT REGIONAL
OFFICE NO. 2ADDRESS CARIGCITY TUGUEGARAO STATE/PROVINCE CAGAYANPOSTAL CODE/ZIP CODE 3500COUNTRY PHILIPPINESMONTHLY SALARY IN LOCAL CURRENCY P 50,000.00BRIEFLY DISCRIBE YOUR DUTIES
I am a CPA/Lawyer. Most of the time I handle legal work – drafting opinions, appeals and decisions, legal consultation. I also do audit work – cash examinations, post audit of government accounts, fraud audit and drafting audit reports.
SECURITY AND BACKGROUND INFORMATIONLOCATION INFORMATIONCURRENT LOCATION TUGUEGARAO CITY
PREPARER OF INFORMATIONDid anyone assist you in filling up this application?Preparer SurnamesPreparer Given NamesOrganization NameStreet AddressCityState/ProvincePostal Zone/Zip CodeCountry Relationship to you
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