Form I-94 Arrival-Departure Record

DEPARTMENT OF HOMELAND SECURITY
U.S. Customs and Border Protection

OMB No. 1651-0111

Welcome to the United States

Admission Number

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I-94 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
17) and the Departure Record (Items 18 through 21).
When all items are completed, present this form to the CBP Officer.
Item 9 - 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.

CBP Form I-94 (XX/08)

Admission Number

OMB No. 1651-0111

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Arrival Record

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, Information Services Branch, 1300 Pennsylvania Avenue, NW, Washington
DC 20229

1.

Family Name

2.

First (Given) Name

3.

Birth Date (Day/Mo/Yr)

4.

Country of Citizenship

5.

Sex (Male or Female)

6.

Passport Issue Date (Day/Mo/Yr)

7.

Passport Expiration Date (Day/Mo/Yr)

8.

Passport Number

9.

Airline and Flight Number

10.

Country Where You Live

11.

12.

City Where Visa Was Issued

14.

Address while in the United States (Number and Street)

15.

City and State

16.

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

17.

Email Address

City Where You Boarded
13. Date Issued (Day/Mo/Yr)

CBP Form I-94 (XX/08)
Departure Number

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OMB No. 1651-0111

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I-94 Departure Record
18.

Family Name

19.

First (Given) Name

21

Country of Citizenship

20.

Birth Date (Day/Mo/Yr)

CBP Form I-94 (XX/08)
See Other Side

STAPLE HERE

THIS SIDE FOR GOVERNMENT USE ONLY
Primary Inspection
Applicant’s Name ___________________________________________________________________________
Date Referred __________________Time ____________________ Insp. No. ___________________________
Reason Referred

212A

PP

Visa

Parole

SLB

TWOV

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__________________________________________________________________________________________

________________________________________________________________________________
Secondary Inspection
End Secondary Time ______________________________

Insp. No. _________________________________

Disposition _________________________________________________________________________________

22. Occupation

23. Waivers

24. CIS A Number

25. CIS FCO

A26. Petition Number

27. Program Number

28.

29.

Bond

Prospective Student

1. Itinerary/Comments
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2.

TWOV Ticket 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
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Departure Record
Port:
Date:
Carrier
Flight No./Ship Name: