Sample Paper Form I-94 Arrival/Departure Record

Sample – PDF Version

Sample Paper Form I-94 Arrival/Departure Record
Sample Paper Form I-94 Arrival/Departure Record

Typed Instructions

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


Department of Homeland Security
U.S. Customs and Border Protection
Welcome to the United States
I94 Arrival/Departure Record – Instructions
This form must be completed by all persons except U.S. citizens, returning resident aliens, aliens with immigrant visas, and Canadian citizens visiting or in transit. 

Type or print legibly with pen in ALL CAPITAL LETTERS. Use English. Do not write on the back of this form. 

This form is in two parts. Please complete both the Arrival Record (Items 1 through 13) and the Departure Record (Items 14 through 17). 

When all items are completed, present this form to the U.S. Immigration and Naturalization Service Inspector. 

Item 7 – If you are entering the United States by land, enter LAND in this space. If you are entering the United States by ship, enter SEA in this space. 

Arrival Record

1. Family Name 

2. First (Given) Name 

3. Birth Date (Day/Mo/Yr) 

4. Country of Citizenship 

5. Sex (Male or Female) 

6. Passport Number 

7. Airline and Flight Number 

8. Country Where You Live 

9. City Where you Boarded 

10.City Where Visa Was Issued 

11. Date Issued (Day/Mo/Yr) 

12. Address while in the United States (Number and Street) 

13. City and State 

Departure Record

14. Family Name 

15. First (Given) Name 

16. Birth Date (Day/Mo/Yr) 

17. Country of Citizenship 


Do not write on this side

Primary Inspection

  • Applicant’s Name
  • Date Referred, Time, Insp.#

Reason Referred

  • ∇ 212A ≅ ≅ ≅ PP ≅Visa ≅Parole ≅ SLB ≅ TWOV
  • ≅ Other

Secondary Inspection

  • End Secondary Time, insp.#
  • Disposition

18. Occupation
19. Waivers
20. CIS A Number A-
22. Petition Number
23. Program Number
24. ≅ Bond
25. ≅ Prospective Student
26. Itinerary/Comments
27. TWOV Ticker Number

Warning – A nonimmigrant who accepts unauthorized employment is subject to deportation.

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.

Students planning to reenter the U.S. within 30 days to return to the same school, see “Arrival-Departure” on page 2 of Form I-20 prior to surrendering this permit.

Record of Changes

Port:Departure Record
Flight #/Ship Name:

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