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.
Type or print legibly with pen in ALL CAPITAL LETTERS. USE ENGLISH
This form is in two parts. Please complete both the Arrival Record. Item 1 through 11 and the Departure Record, items 14 through 17. 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/guardian.
Item 7 - If you are entering the United stated by land, enter LAND in this space. If you are entering the United States by ship, enter SEA in this space.
Admission Number
974825510 02
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Immigration and Naturalization Service
Form I-94W (05-29-91)- Arrival Record
VISA WAIVER
- Family Name
- First (given) Name
- Birth Date (day/mon/yr)
- Country of Citizenship
- Sex (male/female)
- Passport Number
- Airline and flight Number
- Country where you live
- City where you boarded
- Address while in the United States (Number and Street)
- City and State
Government Use Only
12.
13.
Departure Number
974825510 02
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Immigration and Naturalization Service
Form I-94W (05-29-91) - Departure Record
14. Family Name
15. First (given) Name
16. Birth Date (day/mo/yr)
17. Country of Citizenship
Do any of the following apply to you? (Answer Yes or No).
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A. Do you have a communicable disease; physical or mental disorder; or are you a drug abuser or addict?
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Yes/No
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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 or more offenses for which the aggregage sentence to confinemnet was five years seeking entry to engage in criminal or immoral activities?
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Yes/No
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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?
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Yes/No
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D. Are you seeking to work in the U.S.; or have you ever been excluded and deported; or been previously removed from the United Stated; or procured or attempted to procure a visa or entry into the U.S. by fraud or missrepresentation?
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Yes/No
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E. Have you ever detained, retained or withheld custody of a child from a U.S. citizen granted custody of the child?
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Yes/No
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F. Have you ever been denied a U.S. visa or entry into the U.S. or had a U.S. visa canceled? If yes,
When? _________________ Where? _______________
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Yes/No
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G. Have you ever asserted immunity from prosecution?
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Yes/No
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IMPORTANT. If you entered
"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.
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_____________________
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________
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Family Name (please print)
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First Name
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______________________
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________
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Country of Citizenship
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Date of Birth
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WAIVER OF RIGHTS: I hereby waive any rights to review of appeal of an immigration 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.
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_____________________
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________
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Signature
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Date
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Public Reporting Burden - The burden for this collection is computed as follows: (1) Learning about the form 2 minutes; (2) Completing the form 4 minutes for an estimated average of 6 minutes per response. If you have comments regarding the accuracy of the estimate, or suggestions for making this form simpler. You can write to USCIS, 425 1 street, N.W. Rm. 5304, Washington. D.C. 20536 and the office of Management and Budget. Paperwork Reduction Projects. OMB No. 1115-0148, Washington, D.C. 20503
Departure Record
Important: Retain this permit is 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 U.S. only until the date written on this form. To remain past this date, without permission from immigration authorities, is a violation of the law.
Surrnder 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 acccept unathorized 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.
Port:
Date:
Carrier:
Flight #/Ship Name:
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