Form I-94W Nonimmigrant Visa Waiver Arrival Departure (Proposed Ver

Welcome to the
United States

I-94W Nonimmigrant Visa Waiver Arrival/Departure Record
OMB NO. 1651-0111

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 16) and the
Departure Record (Items 19 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 or guardian.
Item 10: 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

This Space For Official Use Only

00000000000
ARRIVAL RECORD Visa Waiver
1

Family Name (Please print, ALL CAPS)

2

First/Given Name

3

Birth Date (DD/MM/YY)

5

Country of Citizenship

6

Country of Birth

7

Passport Issue Date (DD/MM/YY)

9

Passport Number

10

Airline and Flight Number

11

Country Where You Live

12

City Where You Boarded

13

Address While in the United States (Number and Street)

14

City and State

15

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

16

Email Address

4

Sex (Male or Female)

8

Passport Expiration Date (DD/MM/YY)

Government Use Only
17
18
CBP Form I-94W (04/14)
OMB NO. 1651-0111

Admission Number

This Space For Official Use Only

00000000000
DEPARTURE RECORD Visa Waiver
19

Family Name (Please print, ALL CAPS)

20

First/Given Name

21

Birth Date (DD/MM/YY)

22

Country of Citizenship

CBP Form I-94W (04/14)
SEE OTHER SIDE

STAPLE HERE

Do any of the following apply to you? (Answer Yes or No)
A Do you currently have a disease of public health significance? Such diseases

Yes

No

B Have you ever been arrested or convicted for a crime that resulted in serious

Yes

No

C Have you ever violated any law related to possessing, using, or distributing

Yes

No

D Do you seek to engage in or have you ever engaged in terrorist activities?

Yes

No

E Have you ever committed fraud or misrepresented yourself or others to obtain

Yes

No

F Are you currently seeking employment in the United States or were you

Yes

No

G Have you ever been denied a U.S. visa you applied for with your current or

Yes

No

Yes

No

include, but are not limited to:
Chancroid
Gonorrhea
Granuloma Inguinale
Leprosy, infectious

Lymphogranuloma venereum
Syphilis, infectious
Active Tuberculosis

damage to property, or serious harm to another person or government authority?
illegal drugs?

or assist others to obtain a visa or entry into the United States?

previously employed in the United States without prior permission from the
U.S. government?

a previous passport or have you ever been refused admission to the United
States or withdrawn your application for admission at a U.S. port of entry? If yes,
when? _____________________ where? ___________________________________

H Have you ever overstayed a previous period of lawful admission to the United
States, even by one day?

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)

First/Given Name

Country of Citizenship

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


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, including the INA (8 U.S.C. 1103, 1187), and 8 CFR 235.1, 264, and
1235.1. The purposes for this collection are to give the terms of admission and document the
arrival and departure of nonimmigrant aliens to the U.S. The information solicited on this form may
be made available to other government agencies for law enforcement purposes or to assist DHS
in determining your admissibility. All nonimmigrant aliens seeking admission to the U.S., unless
otherwise exempted, must provide this information. Failure to provide this information may deny
you entry to 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. The control number for this collection is 1651-0009. The estimated average time to
complete this application is 4 minutes. Your response is mandatory. If you have any comments regarding
the burden estimate you can write to U.S. Customs and Border Protection Office of Regulations and
Rulings, 90 K Street, NE, 10th Floor, 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 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.
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