2506 13 21:25 Valdson 0144170211 p.1 Consular Electronic Application Cemter - Prim Application 6/18/13 5:32 PM we, US. DEPARTMENT of ST. ee: CONSULAR ELECTRONIC APPLICATION CENTER 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: Hl AA Your Personal Copy -- Do Not Bring to Interview UUM 3 cGoac 0 Personal, Address, Phone, and Passport/Travel Document Information Name Provided: VIEIRA COTRIN, VALDSON Full Name in Native Language: VALDSON VIEIRA COTRIN Other Names Used: Telecode Name Used: Sex: MALE Marital Status: Date of Birth: Place of Birth: Country/Region of Origin (Nationality): Do you hold or have you held any nationality other than the one indicated above on nationality? National Identification Number: U.S. Social Security Number: U.S. Taxpayer ID Number: Home Address: City: State/Province: Postal Zone/ZIP Code: Country/Region: bitps: //ceac. state. gow) GenNIV/common/ printapplication.aspx?omjPPKSC SXkjOmi&2/6G pw4XN48lvDux2bEnmYkveH9L 2 KjOx3d Page 1 of 6 EFTA00286277

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2506 13 21:26 Valdson 0144170211 p.2 Consular Electronic Application Center — Print Application 6/18/13 $:32 PM Visa Number Are you applying for the same type of visa? YES 4 w Are you applying in the same country where the visa above Is issued and ts this country your principal country of residence? Have you been ten-printed? Has your U.S. Visa ever been lost or stolen? Has your U.S. Visa ever been cancelled or revoked? Have you ever been refused a U.S, Visa, or been refused admission to the United States, or withdrawn your application for admission at the port of entry?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 United States Citizenship and Immigration Services? U.S. Contact Information Contact Person Name in the U.S.: Organization Name in the U.S.: DO NOT KNOW Relationship to You: FRIEND U.S. Contact Address: Phone Number: Email Address: Family Information Father's Surnames: DO NOT KNOW Father's Given Names: DO NOT KNOW Mother's Surnames Mother's Given Names; Mother's Date of Birth: DO NOT KNOW Is your mother in the U.S.? | Do you have any immediate relatives, not including parents in the |] Do you have any other relatives in the United States? | Number of former spouses: 1 Former Spouse's Name (1): Date of Birth: Fountry/ Region of Origin (Nationality): Place of Birth City: Date of Marriage: Date Marriage Ended: Place of Birth Country/Region: | | How the Marriage Ended: https: //ceac.state.gov/GenNIV/common/ printapplication aspx 7om)/PPKIC SXkjOm%2 (EC pw4d XN4RIVOUR2 bEnmYkvEHO 2KjOKId Page 3 of 6 EFTA00286278

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2506 13 21:26 Valdson Consular Electronic Appication Center = Print Application Same Mailing Address? Primary Phone Number; Secondary Phone Number: Work Phone Number: Email Address: Passport/Travel Document Type: Passport/Travel Document Number: Passport Book Number: Country/Authority that Issued Passport/Travel Document: City Where Issued: Country/Region Where Issued: Issuance Date; Expiration Date: Have you ever lost a passport or had one stolen? Travel Information © The List of Purposes of Trip to the U.S. Purpose of Trip to the U.S. (1): Specify: Have you made specific travel plans? intended Date of Arrival: Intended Length of Stay in U.S.: Address where you will stay in the U.S.: City, State, Postal/Zip Code: Person/Entity Paying for Your Trip: Are there other persons traveling with you? Are you traveling as part of a group or organization? &, Persons Traveling with You: Name (1): Relationship to You: a Have you ever been in the U.S.? Date Arrived (1): Length of Stay: Do you or did you hold a U.S. Driver's License? = z <i Have you ever been issued a U.S. Visa? Date Last Visa was Issued: 0144170211 p.3 6/18/13 5:32 PM TEMP. BUSINESS PLEASURE VISITOR (B) TOURISM/PERSONAL TRAVEL (62) FRIEND YES 2 WEEK(S) YES 29 OCTOBER 2002 hetps:/ /ceac. State.gov/GenNiV/common/printapplication.aspx?om)PPKIC SXkjOm&2fEGpw4XN48ivDuk2bEamYkvBHOL2KJOK3d Page 2 of 6 EFTA00286279

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2506 13 21:27 Valdson 0144170211 p.4 Consular Electronic Aoplication Center = Print Application 6/18/13 5:32 PM Have you ever committed or conspired to commit a human trafficking offense in the United States or outside the United States? 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? 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? Do you seek to engage in espionage, sabotage, export control violations, or any other illegal activity while in the United States? Do you seek to engage in terrorist activities while in the United States or have you ever engaged in terrorist activities? Have you ever or do you intend to provide financial assistance or other support to terrorists or terrorist organizations? Are you a member or representative of a terrorist organization? Have you ever ordered, incited, committed, assisted, or otherwise participated in genocide? Have you ever committed, ordered, incited, assisted, or otherwise participated in torture? Have you committed, ordered, incited, assisted, or otherwise participated in extrajudicial killings, political killings, or other acts of violence? Have you ever engaged in the recruitment or the use of the child soldiers? Have you, while serving as a government official, been responsible for or directly carried out, at any time, 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? Have you ever been directly involved in the coercive transplantation of human organs or bodily tissue? Have you ever been the subject of a removal or deportation hearing? 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? Have you failed to attend a hearing on removability or inadmissibility within the last five years? Have you ever been unlawfully present, overstayed the amount of time granted by an immigration official or otherwise violated the terms of a U.S. visa? 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? Have you voted In the United States in violation of any law or regulation? Have you ever renounced United States citizenship for the purpose of avoiding taxation? Have you attended a public elementary schoo! on student (F) status or a public secondary school after November 30, 1996 without reimbursing the school? Location Information Location where you will be submitting your application Current Location: BRASILIA, J Preparer of Application Did anyone assist you In filling out this application? i Vaur Darcanal Canny -—- Na Aint Reina ta Tntarviaw https:/ /ceac.state.gov/ GenNIV/common/ printapplication.aspx?om)JPPk9C 5XkjO m%2 f6Gpw4XN48lvDuX2bE Nm YKVBHSL2KjOK3C Page S of 6 EFTA00286280

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2506 13 21:27 Valdson 0144170211 p.5 Consulor Electronic Application Center ~ Print Application 6/18/13 5:32 PM owes © wwe eees ww —S ee Be ey ew tees wee Assinou electronicamente a sua solicitacao em 18-Jun-2013 11:38:04. Foi-lhe pedido para assinar electronicamente a sua solicitagéo, salvo esteja regulamentarmente isento, mesmo que a solicitacao tenha sido preparada por outra pessoa. A sua assinatura electrénica certifica que leu e entendeu as perguntas nesta solicitacfio e que as suas respostas so verdadeiras e correctas Jj melhor do seu conhecimento. A submiss3o de uma solicitagdo contendo quaisquer declaracées falsas ou enganosas poderé resultar na recusa permanente de um visto ou de entrada para os Estados Unidos. Todas as deciaracées feitas nesta solicitagao so declaracées nao ajuramentadas mas feitas sob pena de perjurio. (28.U.S,C,1746) agencias governamentais que tenham autoridade legal para usarem tal informacao, incluindo para p ‘os de aplicacao de lei criminal ou de imigrag&o. A fotografia que forneceu com a sua solicitagio podera ser usada para ver G80 de emprego ou outros A informacao que forneceu na sua solicitac3o e outras informacdes submetida com a sua solicitagao poderdo ser acedidas por outras rp propésitos de aplicac3o da lei Americana. httpsi//ceac, state. gow/GenWiV/common/ printapplication.aspx?omjPPk9IC 5XkjOmk2 16 Cpw4XN4B8ivDuK2 bEnmYkvBH9L 2KjORId Page 6 of 6 EFTA00286281

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2506 13 21:27 Valdson 0144170211 p.6 Consular Electronic Application Center - Print Application S/1S/13 5:32 Pw Country/Region Marriage was Terminated: | Work/Education/Training Information Work Phone Number: Primary Occupation: OTHER Specify Other: MAITRE D HOTEL Present Employer or School Name: EPSTEIN JEFFREY Address: BMI City: ia State/Province: HW Postal Zone/Zip Code: Hill Country/Region: raz Pit Hn Monthly Salary in Local Currency (if employed): Briefly Describe your Duties: SERVIR A TABLE ENTRETIEN DE LA MAISON Were you previously employed? Have you attended any educational institutions at a secondary level or = J} above? Do you belong to a clan or tribe? || & Provide a List of Languages You Speak: Language Name: (1): PORTUGAIS FRNCAIS ANGLAIS Have you traveled to any countries within the last five years? Have you belonged to, contributed to, or worked for any professional, social, or charitable organization? Do you have any specialized skills or training, including firearms, explosives, nuclear, biological, or chemical experience? Have you ever served in the military? Have you ever served in, been a member of, or been involved with a paramilitary unit, vigilante unit, rebel group, guerrilla group, or insurgent organization? Security and Background Information Do you have a communicable disease of public health significance? (Communicable diseases of pubiic 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.) 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? Are you or have you ever been a drug abuser or addict? Have you ever been arrested or convicted for any offense or crime, even though subject of a pardon, amnesty, or other similar action? Have you ever violated, or engaged in a conspiracy to violate, any law relating to controlled substances? 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? Have you ever been involved in, or do you seek to engage In, money laundering? hitps:/ /ceac.state.gov/ GenNIV/common/ printapplication.aspx?om|PPk9C SXkJOM%2 [6Gpw4 XN48IVOURZbEN mY kVBH SL 2KjOKId Page 4 of 6 EFTA00286282