Belgium Interview 1Information relative au Demandeur2Lieu de Livraison3Lieu de l’Entretien4Informations sur les Frais de Visa5Vérification6Paiement AVERTISSEMENT: Chaque voyageur doit remplir son propre formulaire afin d'obtenir son visa. Avant de commencer cette application, assurez-vous que vous avez un passeport valide. Toutes les informations fournies par vous, ou en votre nom par un tiers désigné, doivent être vraies et correctes. Vous pouvez être soumis à des sanctions administratives ou pénales si vous faites sciemment et volontairement une déclaration ou une représentation importante fausse, fictive ou frauduleuse dans une demande d'autorisation de Voyage électronique présentée par vous ou en votre nom.Veuillez prendre le temps de lire la clause des termes et conditions.* J'accepte la clause des termes et conditions. This field is hidden when viewing the formToday's Date DD slash MM slash YYYY Nom*Votre nom doit correspondre à votre passeport et DS-160. Prénom Nom Pays / autorité qui a émis le passeport*Veuillez sélectionnerAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, The Democratic Republic Of TheCook IslandsCosta RicaCroatiaCubaCyprusCzech RepublicCôte D'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran, Islamic Republic OfIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic OfKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States OfMoldova, Republic ofMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalThe NetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian AuthorityPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts And NevisSaint LuciaSaint MartinSaint Pierre And MiquelonSaint Vincent And The GrenedinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard And Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuela, Bolivarian Republic ofViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsPays de naissance*Veuillez sélectionnerAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, The Democratic Republic Of TheCook IslandsCosta RicaCroatiaCubaCyprusCzech RepublicCôte D'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran, Islamic Republic OfIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic OfKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States OfMoldova, Republic ofMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalThe NetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian AuthorityPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts And NevisSaint LuciaSaint MartinSaint Pierre And MiquelonSaint Vincent And The GrenedinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard And Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuela, Bolivarian Republic ofViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsPays de Résidence Permanente*Veuillez sélectionnerAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, The Democratic Republic Of TheCook IslandsCosta RicaCroatiaCubaCyprusCzech RepublicCôte D'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran, Islamic Republic OfIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic OfKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States OfMoldova, Republic ofMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalThe NetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian AuthorityPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts And NevisSaint LuciaSaint MartinSaint Pierre And MiquelonSaint Vincent And The GrenedinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard And Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuela, Bolivarian Republic ofViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsNuméro de passeport*Introduisez le numéro du passeport comme il apparaît dans le passeportCatégorie du visa*Please SelectB1 Business / Conference / Domestic EmployeeB1/B2 Business & Tourism (Temporary visitor)B2 Tourism / Medical TreatmentC1 TransitC1/D Crewmember in transitD1 CrewmemberE1 Treaty Trader / Child of an E1 / Spouse of an E1E2 Treaty Investor / Child of E2 / Spouse of an E2E3 Australian Spec. WorkerE3D Spouse or Child of an E3F1 StudentF2 Spouse or Child of an F1F3 Commuter StudentH1B Speciality OccupationH1B1 Chilean or Singaporean Spec. OccupationH1C Nurse in shortage areaH2A Agricultural WorkerH2B Nonagricultural WorkerH3 TraineeH4 Spouse / Child of H1BH4 Spouse / Child of H1B1H4 Spouse / Child of H1CH4 Spouse / Child of H2AH4 Spouse / Child of H2BH4 Spouse / Child of H3I Foreign Media Representative / Spouse or Child of an IJ1 Professional Exchange Visitor (e.g., physician, scholar)J1 Work Exchange Visitor (e.g., teacher, intern, summer work)J2 Spouse or Child of a J1 - Professional Exchange VisitorJ2 Spouse or Child of a J1 - Work Exchange VisitorL1 Intra-company TransfereeL2 Spouse or Child of an L1M1 StudentM2 Spouse or Child of an M1M3 Commuter StudentO1 Extraordinary AbilityO2 Alien Accompanying/AssistingO3 Spouse or Child of an O1 or O2P1 Internationally Recognized AlienP2 Artist/Entertainer Exchange ProgramP3 Artist / Entertainer in Cultural ProgramP4 Spouse or Child of a P1, P2, or P3Q1 Cultural Exhange VisitorR1 Religious WorkerR2 Spouse or Child of an R1T1 Victim of TraffickingT2 Spouse of a T1T3 Child of a T1T4 Parent of a T1T5/T6 Sibling of a T1 / Derivative Beneficiary of a T1TD Spouse or Child of a TNTN NAFTA ProfessionalU1 Victim of CrimeU2 Spouse of a U1U3 Child of a U1U4 Parent of a U1U5 Sibling of a U1 Introduisez le type de visa sélectionné dans le DS-160.Numéro de pétition*Commence par 3 lettres EAC, WAC, LIN ou SRC, suivi par 10 chiffres. Date de naissance*DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20502049204820472046204520442043204220412040203920382037203620352034203320322031203020292028202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sexe* Homme Femme Téléphone principal*Adresse e-mail* Adresse e-mail Confirmez votre e-mail Vous a-t-on déjà délivré un visa pour entrer aux États-Unis ?* Oui Non Visa émis par*Veuillez sélectionnerBrusselsIssuing Post Not ListedCatégorie du visa précédent*Please SelectB1 Business / Conference / Domestic EmployeeB1/B2 Business & Tourism (Temporary visitor)B2 Tourism / Medical TreatmentC1 TransitC1/D Crewmember in transitD1 CrewmemberE1 Treaty Trader / Child of an E1 / Spouse of an E1E2 Treaty Investor / Child of E2 / Spouse of an E2E3 Australian Spec. WorkerE3D Spouse or Child of an E3F1 StudentF2 Spouse or Child of an F1F3 Commuter StudentH1B Speciality OccupationH1B1 Chilean or Singaporean Spec. OccupationH1C Nurse in shortage areaH2A Agricultural WorkerH2B Nonagricultural WorkerH3 TraineeH4 Spouse / Child of H1BH4 Spouse / Child of H1B1H4 Spouse / Child of H1CH4 Spouse / Child of H2AH4 Spouse / Child of H2BH4 Spouse / Child of H3I Foreign Media Representative / Spouse or Child of an IJ1 Professional Exchange Visitor (e.g., physician, scholar)J1 Work Exchange Visitor (e.g., teacher, intern, summer work)J2 Spouse or Child of a J1 - Professional Exchange VisitorJ2 Spouse or Child of a J1 - Work Exchange VisitorL1 Intra-company TransfereeL2 Spouse or Child of an L1M1 StudentM2 Spouse or Child of an M1M3 Commuter StudentO1 Extraordinary AbilityO2 Alien Accompanying/AssistingO3 Spouse or Child of an O1 or O2P1 Internationally Recognized AlienP2 Artist/Entertainer Exchange ProgramP3 Artist / Entertainer in Cultural ProgramP4 Spouse or Child of a P1, P2, or P3Q1 Cultural Exhange VisitorR1 Religious WorkerR2 Spouse or Child of an R1T1 Victim of TraffickingT2 Spouse of a T1T3 Child of a T1T4 Parent of a T1T5/T6 Sibling of a T1 / Derivative Beneficiary of a T1TD Spouse or Child of a TNTN NAFTA ProfessionalU1 Victim of CrimeU2 Spouse of a U1U3 Child of a U1U4 Parent of a U1U5 Sibling of a U1Date d'émission du visa*DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20502049204820472046204520442043204220412040203920382037203620352034203320322031203020292028202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date d'expiration du visa*DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20502049204820472046204520442043204220412040203920382037203620352034203320322031203020292028202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Voyagez-vous depuis un autre pays pour demander un visa pour les États-Unis en Belgique?* Oui Non Cochez toutes les déclarations qui s'appliquent* You have a residence permit from Belgium and will bring the residence permit to his/her appointment. (Please note that identifying as having a residency permit incorrectly will result in the cancellation of your appointment.) You are a European Union, European Economic Area, or Swiss citizen resident in Belgium, or a citizen from another country resident in Belgium with a valid Belgian residency card. You are physically present in Belgium The previous visa that you are renewing was issued when you were 14 years of age or older. You answered 'NO' to all of the 'Medical and Health', 'Criminal', 'Security' or 'Immigration Law Violation' questions on the DS-160 Visa application form. None of the above apply Le retour de vos documents vers une adresse personnelle ou professionnelle est inclus dans vos frais de demande de visa. Veuillez remplir l’adresse vers laquelle les documents doivent être envoyés.Lieu pour retirer vos documents (sans frais supplémentaires)*Mikropakket Belgium NV - Havendoklaan, Vilvoorde, 1800À l'attention de* Prénom Nom Veuillez entrer la date de votre entretien desirée Veuillez noter que des rendez-vous peuvent être disponibles en cas d'urgence. Si la date que vous recevez ne correspond pas à vos plans de voyage, veuillez nous envoyer un email et nous vous demanderons un rendez-vous accéléré. Vous recevrez une confirmation officiel de votre date et heure d'entretien.Sélectionnez le consulat américain préféré pour votre entrevue de visa.*veuillez sélectionnerBrusselsDate de l'entretien* DD slash MM slash YYYY Détails des frais MRV : Les frais seront attribués au candidat {applicant_name (First):15.3} {applicant_name (Last):15.6} né le {applicant_birth_day:21} en {applicant_birth_country_code:16}, les informations du candidat ne pourront plus être modifiées après le paiment. Les frais ne sont ni remboursables ni transférables (soit à une autre personne, soit pour une utilisation dans un autre pays) Vous pouvez mettre à jour votre adresse e-mail et votre numéro de téléphone à tout moment. Vous ne pouvez changer votre numéro de passeport qu'une (1) fois après qu'un paiement ait été effectué. Tous les demandeurs de visa, y compris les enfants, sont tenus de payer des frais de demande de visa non immigrant (MRV), non remboursables et non transférables. Le paiement des frais de demande de visa est requis, qu'une demande aboutisse ou non à la délivrance d'un visa américain.Conditions générales d'utilisation*Je confirme que les informations fournies sur ce formulaire sont correctes et exactes au mieux de mes connaissances. J'ai lu et accepté la clause de non-responsabilité, les conditions générales et la politique de non-remboursement et je comprends qu'il s'agit d'un traitement par une tierce partie. Si un détenteur de carte tente de signaler faussement qu'une transaction était frauduleuse et demande une imputation des frais de demande, l'ambassade américaine en sera informée. Cela peut entraîner l'annulation de tout visa déjà prévu. J'accepte les conditions d'utilisation Confirmez {all_fields} DS-160 Application and MRV Visa Fee*Total $0.00 Signature électronique du demandeur* Prénom Nom Veuillez entrer le nom du demandeurAdresse de facturation* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Informations de paiement* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Numéro de carte Month010203040506070809101112 Year20252026202720282029203020312032203320342035203620372038203920402041204220432044 Date d'expiration Code CVV Nom du porteur Numéro de téléphone du titulaire de la carte*Numéro de téléphone de la personne payant le rendez-vous. Adresse e-mail du titulaire de la carte* Enter Email Confirm Email Adresse email de la personne payant le rendez-vous. E-Signature of Cardholder* First Last Signature de la personne payant le rendez-vous. Relationship with Applicant*Please SelectSelfFamily Member (Spouse/Partner/Parent/Sibling/Child/Other Relative)FriendCoworkerEmployerEmployeeBusiness PartnerClient/CustomerRelationship that you have with the visa applicant.Cardholder Signature*Signature of the person paying for the appointment.Consent and Authorization*I certify under penalty of perjury under the laws of the United States of America that the foregoing is true and correct. I acknowledge and approve that entering my name in the signature field legally replace my physical signature. I understand that by providing this authorization, I am consenting to UVA managing these processes on my behalf, and I confirm that I am fully responsible for any charges incurred as part of this service. I acknowledge that UVA is not affiliated with the United States government. I hereby authorize UVA to act on my behalf to make appointments and pay the non-refundable MRV fee for the purpose of this transaction. I Consent and Authorize this transaction.