Application Form - Formulari i Aplikimit [English] Fill out all the fields below in English. You are responsible for the data you provide, which will be reflected in your medical forms to the U.S. Embassy. Each visa applicant must submit his or her own form, regardless of age. Apply only once please! Do NOT type special characters [~,",'] in the forms, as you will not be able to submit the form. Check your email and/or junk/spam folder three business days after you submit your application. [Albanian] Plotësoni të gjitha pyetjet e mëposhtme në Anglisht. Ju jeni përgjegjës për informacionin që jepni, i cili do të pasqyrohet tek formularët mjekësorë që do të dorëzohen në Seksionin Konsullor. Secili aplikant i vizës duhet të plotësojë dhe të dorëzojë një formular më vete. Lutemi aplikoni vetëm një herë! Ju lutemi MOS përdorni karaktere të veçanta si [~,",'] pasi nuk lejon dërgimin me sukses të formularit! Tre ditë pas dorëzimit të formularit kontrolloni emailin tuaj dhe/ose spam/junk email. Select the Clinic*Muzha ClinicCela ClinicZgjidhni klinikën ku dëshironi të kryeni vizitën mjekësoreInterview Date* Date Format: MM slash DD slash YYYY If you are a K-Visa Applicant (Fiance(e), or if you have to repeat the medical examination, or if you are instructed by the Consular Section to undergo the medical examination without having a visa interview date first, please enter as the visa interview date a date three weeks away from the date of the medical form submission. Note that this date will not be your visa appointment date, it is solely used for scheduling your medical appointment date only. [ALB] Nëse jeni një aplikant i vizës K (të fejesës), ose nëse do të përsërisni vizitën mjekësore, apo nëse Seksioni Konsullor ju ka kërkuar të kryeni vizitën mjekësore pa patur një takim të caktuar, lutemi vendosni si datë takimi një datë tre javë nga data që po dorëzoni këtë formular. Kini parasysh që ajo datë nuk do të jetë data juaj e takimit për vizë, ajo do të përdoret vetëm për caktimin e takimit të vizitës mjekësore. Passport Number*Numri i PasaportësAlien (case) Number (example: TIA201912345678, or 2019EU12345*Numri i çështjes tuaj (p.sh: TIA201912345678, ose 2019EU12345)Last Name*Last Name - MbiemriFirst Name*First Name - EmriBirth Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Datëlindja në formatin muaj/datë/vitSex(M,F)*MFGjiniaCity and Country of Birth*Qyteti dhe Shteti ku keni lindurPresent Country of Residence* AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Shteti ku jetoni aktualishtPrior Country* AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Shteti ku keni jetuar më parëPresent Address of Residence* Street Address Address Line 2 City ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Adresa aktuale e banimitIntended US Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Adresa në SHBAE-Mail Address* Enter Email Confirm Email Applicant Category*ImmigrantSpecial Immigrant (SIV)DiversityAdopteeRefugeeVisa 92AsyleeVisa 93K-VisaOther NIVParoleeKategoria e vizësPhone*Numër telefoniEducation*Early ChildhoodEducationalBachelorMasterArsimi juajProfession*ProfesioniWeight*Please enter a number from 0 to 200.Pesha në KgHeight*Please enter a number from 0 to 250.Gjatësia në cmIllness or injury requiring hospitalization (including psychiatric)*YesNoA jeni shtruar në spital për shkak të sëmundjeve apo dëmtimeve (përfshirë sëmundje psikike)?Explain:Any surgical procedure or caesarian section?*YesNoA keni kryer ndonjë operacion ose lindje me operacion?Explain:ShpjegoniHeart Disease*YesNoSëmundje të ZemrësExplain:Angina pectoris (infarcts, pre-infarcts)*YesNoInfarkt, Para infarktExplain:Hypertension (high blood pressure)*YesNoHipertension (tension i lartë i gjakut)Explain:Cardiac arrhythmia*YesNoAritmi kardiakeExplain:History of tobacco use*YesNoA keni pirë duhan?Explain:ShpjegoniAre you currently smoking*YesNoA pini aktualisht duhan?Explain:Asthma*YesNoAzmaExplain:Chronic obstructive pulmonary disease (emphysema)*YesNoSëmundje të mushkëriveExplain:History of tuberculosis (TB) disease*YesNoA keni qenë i sëmurë me Tuberkuloz?Explain:Have you ever been treated for TB?*YesNoA jeni trajtuar për Tuberkuloz?Explain:Do you have current symptoms of TB?*YesNoA keni aktualisht simptoma të Tuberkulozit?Explain:Are you under treatment for TB?*YesNoA jeni aktualisht nën trajtim mjekësor për Tuberkuloz?Explain:History of stroke, with any current impairment*YesNoA keni patur hemorragji cerebrale, me ndonjë dëmtim të tanishëmExplain:Shpjegoni:Seizure disorder*YesNoKrizë epileptikeExplain:Major impairment in learning, intelligence, self-care, memory or communication*YesNoDëmtim në nxënie, të menduar, përkujdesje të vetes, kujtesës, ose komunikimitExplain:Shpjegoni:Major mental disorder (including major depression, bipolar disorder, schizophrenia, mental retardation)*YesNoÇrregullime mendore (përfshirë depresion, çrregullim bipolar, skizofreni, apo zhvillim mendor i vonuar)Explain:Use of drugs other than those required for medical reasons*YesNoPërdorim ilaçesh përtej atyre të rekomanduara për arsye mjekësoreExplain:Addiction or abuse of specific* substance (drug). *amphetamines, cannabis, cocaine, hallucinogens opioids, phencyclidines, sedative-hypnotics, anxiolytics*YesNoI varur nga apo abuzim i substancave specifike (droga): amfetaminë, kanabis, kokainë,opioide hallucinogjenike , phencyclidines, sedativët hipnotizues, anxiolyticsExplain:Other substance-related disorder (including alcohol addiction or abuse)*YesNoÇrregullim nga substanca të tjera (përfshirë varësi nga alkoli, ose abuzim me alkolin )Explain:Have you ever attempted suicide?*YesNoA jeni përpjekur të vetëvriteni?Explain:Have you ever caused SERIOUS injury to others, caused MAJOR property damage or had trouble with the law because of medical condition, mental disorder, or under the influence of alcohol or drugs*YesNoA u keni shkaktuar ndonjëherë lëndime të rënda të tjerëve, duke shkaktuar dëmtim të madh të pronës ose keni pasur probleme me ligjin për shkak të gjendjes shëndetësore, çrregullimeve mendore ose nën ndikimin e alkoolit apo të drogës?Explain:Are you pregnant?*YesNoA jeni shtatzënë?If so, list Estimated Delivery date:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920mm/dd/yyyy. Nëse po data e parashikuar e lindjes në formatin muaj/datë/vitProvide dates of birth of all biological children: birth date 1:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920mm/dd/yyyy. Shkruani ditëlindjet e të gjithë fëmijëve biologjikë që keni lindurBiological children birth date 2:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920mm/dd/yyyyBiological children birth date 3:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920mm/dd/yyyyBiological children birth date 4:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920mm/dd/yyyyBiological children birth date 5:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920mm/dd/yyyyBiological children birth date 6:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920mm/dd/yyyyDo you have any sexually transmitted disease?*YesNoA vuani nga sëmundje që transmetohen seksualisht?Specify:Diabetes mellitus*YesNoA vuani nga diabeti?Specify:Thyroid disease*YesNoTiroide?Specify:History of malaria*YesNoA keni vuajtur ndonjëherë nga malaria?Specify:Malignancy*YesNoSpecify:Chronic renal disease*YesNoSëmundje kronike renale?Specify:Chronic hepatitis or other chronic liver disease*YesNoHepatit kronik ose sëmundje të tjera kronike të mëlçisë?Specify:Hansens Disease (Leprosy)*YesNoLeprozë?Specify:Hansens Disease (select if yes)MultibacilarPaubacilarSpecify:Treated?YesNoSpecify:Do you have vision problems (glasess etc.)*YesNoA keni probleme me shikimin (syze, etj.)? Specify:Chickenpox infectious disease*YesNoA vuani nga Lija e Dhenve?Specify:Did you ever belong to a physically disable group?*YesNoA keni qenë ndonjëherë pjesë e ndonjë grupi me aftësi të kufizuara fizike?Specify:Do you have visible disabilities (including loss of limb):*YesNoA keni mangësi të dukshme (përfshirë edhe mangësi gjymtyrësh)?Specify:Do you have other conditions requiring treatment?*YesNoA keni sëmundje të tjera që kërkojnë trajtim mekësor?Explain:Have you had or currently have any other medical issues for which you have not been explained the origin (for example: weight loss, prolonged fever, etc.)?*YesNoA keni pasur ose keni aktualisht ndonjë problem tjetër mjekësor, origjina e të cilit nuk është zbuluar? (për shembull: humbje peshe, ethe e tejzgjatur, etj.)?If YES, describe:Did you serve in the military service?*YesNoA e keni kryer shërbimin ushtarak?If not, explain why?Nëse jo, shpjegoni përse?Civil Status*Single - Beqar/eMarried - i/e martuarWidowed - i/e veDivorced - i/e ndarëUpload the applicant photo (ngarkoni foton e aplikantit)Accepted file types: jpg.The photo should be 3.5 cm x 4.5 cm in jpg format ,and be named under applicat's name. (ex. name_surname.jpg) Foto duhet te kete permasat 3.5 cm x 4.5 cm ne format jpg dhe të emërtohet në emrin e aplikantit, si p.sh.: emer_mbiemer.jpg. Vaccination card (Ngarko Kartelën e Vaksinimit)Accepted file types: jpg, png, bmp, pdf.Save the files with the aplicant name for ex. (agim_toska.pdf)Select the clinic_old*Cela ClinicMuzha ClinicEmailThis field is for validation purposes and should be left unchanged.