Form I-94W Nonimmigrant Visa Waiver Approval/Departure

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

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 22). 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 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.
Admission Number

0 0 0 0 0

0 0 0 0

0

0

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

VISA WAIVER
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)

Government Use Only
18.

19.

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

0 0 0 0 0

0 0 0 0

OMB No. 1651-0111

0

0

DEPARTMENT OF HOMELAND SECURITY
U.S. Customs and Border Protection
VISA WAIVER
20

Family Name

21.

First (Given) Name

22.

Country of Citizenship

20.

Birth Date (Day/Mo/Yr)

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

STAPLE HERE

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?

B.

Yes

No

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 or immoral 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 it 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

Yes

No

E.

Have you ever detained, retained or withheld custody of a
child from a U.S. citizen granted custody of the child?

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

Have you ever asserted immunity from prosecution?

Yes

No

G.

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.
_________________________
Family Name (Please print)

_________________________
Country of Citizenship

____________________________
First Name

____________________________
Date of Birth

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

___________
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, Information Services Branch,1300 Pennsylvania
Avenue, NW, 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 dater 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 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: