CBP Form I-94W Non Immigrant Visa Waiver Arrival/Departure Record

Welcome to the United States
I-94W Nonimmigrant Visa Waiver Arrival/Departure Record
ARRIVAL RECORD Visa Waiver
Instructions

OMB NO. 1651-0111

CBP Form I-94W (12/16)

Admission Number

This form must be completed by every nonimmigrant visitor not in possession of a visitor’s visa who
is a national of one of the countries enumerated in 8 CFR 217. The airline can provide you with the
current list of eligible countries.

This Space For Official Use Only

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Type or print legibly with pen in ALL CAPITAL LETTERS. USE ENGLISH.
This form is in two parts. Please complete both the Arrival Record (Items 1 through 8) and the
Departure Record (Items 1 through 4). The reverse side of this form must be signed and dated.
Children under the age of fourteen must have their form signed by a parent or guardian.

1 Applicant Information
Applicant Name (Please print, ALL CAPS)
Family Name

Are you known by any other names or aliases?
Other Names/Aliases
Family Name
Parents
Family Name

4 Contact Information
E-mail Address
First (Given) Name

Yes

Telephone Number
Country Code/Number

No

First (Given) Name

Home Address
Address Line 1

First (Given) Name

Birth Date (DD/MM/YY)

Apartment Number

Address Line 2

City

State/Province/Region

Country

(Optional) Please enter information associated with your online presence.
Provider
Social Media Identifier

City of Birth

5 Emergency Contact Information

Country of Birth

Emergency Contact
Family Name

First (Given) Name

Gender (Male or Female)
Telephone Number
Country Code/Number

2 Passport Information

E-mail Address

Passport Number
Passport Issuing Country
Issuance Date (DD/MM/YY)

6 Travel Information
Is your travel to the U.S. occurring in transit to another country?
Yes
Address while in the United States
Address Line 1
Apartment Number

Expiration Date (DD/MM/YY)

No

Country of Citizenship
City

Address Line 2
National Identification Number

State
Are you a member of CBP Global Entry?
Please provide your Pass ID number.

3 Citizenship Information
Are you now a citizen or national of any other country?
If yes, what countries?

Yes

No

No
SEE OTHER SIDE
OMB NO. 1651-0111

How did you acquire citizenship?

Admission Number

Have you ever been a citizen or national of any other country?
If yes, what countries?

Yes

This Space For Official Use Only

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No

Have you ever been issued a passport or national identity card for travel by any
other country?
If yes, what is the document number?
Expiration Date

Additional document number

Yes

Yes

No

DEPARTURE RECORD Visa Waiver
1

Family Name (Please print, ALL CAPS)

2

First/Given Name

3

Birth Date (DD/MM/YY)

4

Country of Citizenship

Expiration Date

If you need more space to answer any of the questions please add it here.

CBP Form I-94W (12/16)
STAPLE HERE

Do any of the following apply to you? (Answer Yes or No)

7 U.S. Point of Contact Information
U.S. Point of Contact
Address
Address Line 1
Address Line 2

1 Do you have a physical or mental disorder; or are you a drug abuser or addict;

Yes

No

2 Have you ever been arrested or convicted for a crime that resulted in serious

Yes

No

3 Have you ever violated any law related to possessing, using, or distributing

Yes

No

4 Do you seek to engage in or have you ever engaged in terrorist activities,

Yes

No

5 Have you ever committed fraud or misrepresented yourself or others to obtain

Yes

No

6 Are you currently seeking employment in the United States or were you

Yes

No

7 Have you ever been denied a U.S. visa you applied for with your current or

Yes

No

8 Have you ever stayed in the United States longer than the admission period

Yes

No

9 Have you traveled to, or been present in, Iran, Iraq, Libya, Somalia, Sudan,

Yes

No

or do you currently have any of the following diseases (communicable diseases
are specified pursuant to section 361(b) of the Public Health Service Act)?

Apartment Number

Cholera

Yellow Fever

Diphtheria

 iral Hemorrhagic Fevers, including Ebola,
V
Lassa, Marburg, Crimean-Congo

Tuberculosis, infectious

City

Plague
State

Smallpox

Telephone Number
Country Code/Number

 evere acute respiratory illnesses capable
S
of transmission to other persons and
likely to cause mortality.

damage to property, or serious harm to another person or government authority?

illegal drugs?

8 Employment Information
Do you have a current or previous employer?

Yes

No

espionage, sabotage, or genocide?

Employer Name
Address
Address Line 1

or assist others to obtain a visa or entry into the United States?

Apartment Number

Address Line 2

City

State/Province/Region

Country

previously employed in the United States without prior permission from the
U.S. government?

a previous passport or have you ever been refused admission to the United
States or withdrawn your application for admission at a U.S. port of entry? If yes,
when? _____________________ where? ___________________________________

Telephone Number
Country Code/Number

granted to you by the U.S. government?

Job Title

Syria, or Yemen on or after March 1, 2011?
If yes was it for
Official government business

5 U.S.C. § 552a(e)(3) PRIVACY ACT NOTICE: Information collected on this form
is required by Title 8 of the U.S. Code, including the INA (8 U.S.C. 1103, 1187),
and 8 CFR 235.1, 264, and 1235.1. The purposes for this collection are to give
the terms of admission and document the arrival and departure of nonimmigrant
aliens to the U.S. The information solicited on this form may be made available
to other government agencies for law enforcement purposes or to assist DHS
in determining your admissibility. All nonimmigrant aliens seeking admission to
the U.S., unless otherwise exempted, must provide this information. Failure to
provide this information may deny you entry to the United States and result in
your removal.
PAPERWORK REDUCTION ACT STATEMENT: An agency may not conduct or
sponsor an information collection and a person is not required to respond to
this information unless it displays a current valid OMB control number. The
control number for this collection is 1651-0111. The estimated average time to
complete this application is 16 minutes. If you have any comments regarding this
burden estimate you can write to U.S. Customs and Border Protection, Office of
Regulations and Rulings, 90 K Street, NE, 10th Floor, Washington, DC 20229.

Departure Record
IMPORTANT: Retain this permit in your possession; you must surrender it when you leave the U.S.
Failure to do so may delay your entry into the U.S. in the future.
You are authorized to stay in the U.S. only until the date written on this form. To remain past this
date without permission from Department of Homeland Security authorities, is a violation of the law.
Surrender this permit when you leave the U.S.:
• By sea or air, to the transportation line;
• Across the Canadian border, to a Canadian Official;
• Across the Mexican border, to a U.S. Official.
WARNING: You may not accept unauthorized employment; or attend school; or represent the foreign
information media during your visit under this program. You are authorized to stay in the U.S. for 90
days or less. You may not apply for: 1) a change of nonimmigrant status; 2) adjustment of status to
temporary or permanent resident, unless eligible under section 201(b) of the INA; or 3) an extension
of stay. Violation of these terms will subject you to deportation. Any previous violation of this program,
including having previously overstayed on this program without proper DHS authorization, may result
in a finding of inadmissibility as outlined in Section 217 of the Immigration and Nationality Act.
Port
Date
Carrier
Flight No./Ship Name

Military service on behalf of a Visa Waiver Program country

If yes, when?

IMPORTANT: If you answered “Yes” to any of the above, please contact the American Embassy
BEFORE you travel to the U.S. since you may be refused admission into the United States.
WAIVER OF RIGHTS: I hereby waive any rights to review or appeal of a U.S. Customs and Border
Protection officer’s determination as to my admissibility, or to contest, other than on the basis of
an application for asylum, any action in deportation.
CERTIFICATION: I certify that I have read and understand all the questions and statements on this
form. The answers I have furnished are true and correct to the best of my knowledge and belief.
Signature

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Date