Form I-95 Crewman's Landing Permit

OMB N0. 1651-0114
DEPARTMENT OF HOMELAND SECURITY

U.S. Customs and Border Protection
CREWMAN’S LANDING PERMIT
Family Name

Expires 10/31/2011
FIN or “A” No.

Given Name

Home Address

Initial

Address in United States
Hair

Eyes

Ht.

Wt.

Date of Birth
Place of Birth
Passport Number/Nationality
Arrived by

Air

Sea

CBP Form I-95 (XX/12)

CREWMAN’S LANDING PERMIT
Department of Homeland Security – U.S. Customs and Border Protection
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, specifically the Immigration and Nationality Act (8 U.S.C.
1282) and 8 CFR 251.1(c), 252.1(e) and 264.1. The purpose of this collection is to
provide for the application and approval of alien crew members for permission to
temporarily land in the United States. The information solicited on this form will be used
to assist DHS in determining your eligibility for such privileges and may be made available
to other government agencies for law enforcement purposes, as necessary. All alien
crew members seeking to land in the U.S., unless otherwise excepted, must provide this
information. Failure to provide this information may result in a denial to land in the United
States and result in your removal.

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 and an expiration date. The control number
for this collection is 1651-0114. The estimated average time to complete this application is
5 minutes. If you have any comments regarding the burden estimate you can write to
th
U.S. Customs and Border Protection, Office of Regulations and Rulings, 799 9 Street,
NW., Washington DC 20229.
CBP Form I-95 (XX/12)

Arrival
Date

Place of
Arrival

CBP Officer Signature

By accepting this conditional permit to land, the holder agrees to all the
conditions incident to the issuance thereof and to deportation from the United
States in accordance with the provisions of section 252(b) of the Immigration
and Nationality Act.

CBP Form I-95 (XX/12)