Do any of the following apply to you? (Answer Yes or No) 
A. Do you have a communicable disease; physical or mental disorder; or are you a drug abuser or addict? B. Have you ever been arrested or convicted for an offense or crime involving moral turpitude or a violation related 
to a controlled substance; or been arrested or convicted for two ro more offenses for which the aggregate sentence to confinement was five years or more; or been a controlled substance trafficker; or are you seeking entry 
to engage in criminal or immoral activities? C. Have you ever been or are you now involved in espionage or sabotage; or in terrorist activities; or genocide; or between 1933 and 1945 were you involved, in any way, in 
persecutions associated with Nazi Germany or its allies? D. Are you seeking entry by fraud or misrepresentation? E. Have you ever detained, retained or witheld custody of a child from a U.S. citizen granted custody of the 
child? IMPORTANT: If you have answered YES to any of the above, please contact the American Embasy BEFORE you travel to the U.S. since you may be refused admission into the United States.