WRITTEN AUTHORIZATION UNDER THE PROVISIONS OF THE PRIVACY ACT OF 1974
For Non-Immigrant Visitor Visa

Date: __________________________

Dear Congressman Holt,

I would like to request assistance with the following problem I am having with the U.S. Embassy/Consulate listed below. In keeping with the restrictions of the Privacy Act of 1974, I am authorizing you and/or your staff to request information on me, which would be required in your investigation of the matter, outlined below.

Mr. or Ms. (Circle One) Name: ___________________________________________

Address: __________________________________________________________

City: __________________________________ ZIP: _______________________

Home Phone: ____________________ Work/Cell Phone: ___________________

Email Address: _____________________________________________________

Signature: x ________________________________________________________

Mr. or Ms. (Circle One) Name of Applicant: ________________________________

Applicant’s Passport Number: _________________________________________

Applicant’s Date of Birth: ____________________________________________

Applicant’s Current Address: __________________________________________

Embassy or Consulate being used: ______________________________________

Has an appointment for an interview been set? ____________________________

If yes, what is the date and time of the interview? __________________________

Has an application already been denied? _________________________________

Briefly explain your relationship to the visa applicant and his/her reason for wanting to come to the United States:

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

At what point in the visa application process is the applicant? (Has an application been submitted? Has an appointment for an interview been set? Has an application already been denied?):

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

What ties to the home country can the applicant demonstrate? (Is he/she married? Does he/she own a home or have a job? Do his/her parents and/or siblings still live there?) Please answer with as much detail as possible, as the Department of State seeks compelling evidence that each visitor does not intend to immigrate to the United States.

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

Thank you.

Please return this form to:
Rep. Rush Holt
50 Washington Road
West Windsor, New Jersey 08550

Fax: (609) 750-0618