Form I-192 Form I-192 Application for Advance Permission to Enter as Nonimmigr

OMB No. 1615-0017; Expires 01/31/12

DRAFT
Department of Homeland Security

I-192, Application for Advance
Permission to Enter as Nonimmigrant
[Pursuant to Section 212(d)(3)(A)(ii) of the INA]

U.S. Citizenship and Immigration Services

Fee Stamp

(Read instructions to the form.)
Type or Print in Black Ink

File No. AI hereby apply to the Secretary of Homeland Security for permission to enter the United States temporarily under the provisions of
section 212(d)(3)(A)(ii) of the Immigration and Nationality Act (INA).
2. Date of Birth (mm/dd/yyyy)

1. Full Name

4. Present Citizenship/Nationality

3. Place of Birth (City-Town, State/Province, Country)
5. Present Address, Telephone Number, and E-Mail address

6. All addresses at which I have resided during the past 5 years (Use a separate sheet of paper, if necessary.)

7. Desired Port of Entry into the United States
9. Proposed Date of Entry

8. Means of Transportation
10. Approximate Length of Stay in the United States

11. My purpose for entering the United States is: (Explain fully)

12. I believe that I may be inadmissible to the United States for the following reason(s) and no others:

13. I
on

have

have not previously filed an application for advance permission to enter as a nonimmigrant

,

, at

.

If you are an applicant for T and U nonimmigrant status, you do not need to answer questions 14 through 17.
14. Have you ever been in the United States for a period of 6 months or more? If yes, when, for how long, and in what immigration status?

Form I-192 (Rev. 08/10/10)Y

15. Have you ever filed an application or petition for immigration benefits with the U.S. Government, or has one ever been filed on your
behalf? If yes, list the applications and/or petitions, the filing locations, and describe the outcome of each application/petition (for
example: denied, approved, pending).

16. Have you ever been denied or refused an immigration benefit by the U.S. Government, or had a benefit revoked or terminated
(including but not limited to visas)? Describe in detail.

17. Have you ever, in or outside the United States, been arrested, cited, charged, indicted, fined, or imprisoned for breaking or violating any
law or ordinance, excluding minor traffic violations? Describe in detail. Include all offenses where impaired driving may have been
an issue.

18. Applicant's Signature and Certification
I understand that the information herein contained may be used in any proceedings (including civil, criminal, immigration, or any
other judicial proceeding) hereafter instituted against me.
I certify that the statements above and all attachments hereto are true and correct to the best of my knowledge and belief.

(Signature of Applicant)

(Date)

Signature of the Applicant/Signature of Guardian or Family Member (if Applicant is unable to sign)

19. Preparer's Signature and Certification
I declare that this document was prepared by me at the request of the applicant or qualified relative/legal guardian of the applicant, and it is based on
all information of which I have knowledge and/or was provided to me by the above named person in response to the exact questions contained on
this form. I have not knowingly withheld any information.

(Signature)

(Address)
RECEIVED

TRANS. IN

(Date)
RET'D TRANS.
OUT

COMPLETED

Form I-192 (Rev. 08/20/10)Y Page 2