Sample I-94W Nonimmigrant Visa Waiver Arrival/Departure Form




 Typed Instructions
Typed instructions from the form above are provided below just in case you can't read it properly in the scanned image.


Department of Homeland Security
U.S. Customs and Border Protection
OMB No.1651-0111
Welcome to the United States

I-94W Nonimmigrant Visa Waiver Arrival/Departure Form

Instructions
FRONT

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 (Items 1 through 17) and the Departure Record (Items 20 through 23). 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.

Item 9 - 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.

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.
Admission Number
199767179 20
----------------
Arrival Record
VISA WAIVER
  1. Family Name


  2. First (Given) Name


  3. Birth Date (DD/MM/YY)


  4. Country of Citizenship


  5. Sex (Male or Female)


  6. Passport Issue Date (DD/MM/YY)


  7. Passport Expiration Date (DD/MM/YY)


  8. Passport Number


  9. Airline and Flight Number


  10. Country Where You Live


  11. Country Where You Boarded


  12. City Where Visa Was Issued


  13. Date Issued (DD/MM/YY)


  14. Address While in the United States (Number and Street)


  15. City and State


  16. Telephone Number in the U.S. Where You Can Be Reached


  17. Email Address


  18. Government Use Only





  19. CBP Form I-94W (05/08)

    OMB No. 1651-0111


    Admission Number

    199767179 20
    ----------------
    Departure Record
    VISA WAIVER

  20. Family Name


  21. First (Given) Name


  22. Birth Date (MM/DD/YY)


  23. Country of Citizenship


BACK

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?

Yes/No
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 aggregate sentence to confinement was five years or more; or been a controlled substance trafficker, or are you seeking entry to engage in criminal activities?

Yes/No
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 involved, in any way, in persecutions associated with Nazi Germany or its allies?

Yes/No
D. Are you seeking to work in the U.S.; or have ever been excluded and deported; or been previously removed from the United States; or procured or attempted to procure a visa or entry into the U.S. by fraud or misrepresentation?

Yes/No
E. Have you ever detained, retained or withheld custody of a child from a U.S. citizen granted custody of the child?

Yes/No
F. Have you ever been denied a U.S. visa or entry into the U.S. or had a U.S. visa cancelled? If yes,
When? _________________ Where? _______________

Yes/No
G. Have you ever asserted immunity from prosecution?

Yes/No
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.

_____________________ ________
Family Name (please print)
First Name
______________________ ________
Country of Citizenship
Date of Birth

WAIVER OF RIGHTS: I hereby waive any rights to review of appeal of 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
Date

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 8 minutes per respondent. If you have any comments regarding the burden estimate you can write to U.S. Customs and Border Protection, Asset Management, 1300 Pennsylvania Avenue, NW Washington D.C. 20229


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 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 nor 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 a proper DHS authorization, will result in a finding of inadmissibility as outlined in Section 217 of the Immigration and Nationality Act.

Port:

Date:

Carrier:

Flight No./Ship Name:


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