Information Collection |
Form I-94W/ESTA Current version |
Form I-94/ESTA Revised version |
Family name, First name |
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Date of birth |
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Country of birth |
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Country of citizenship |
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Gender |
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Airline and Flight Number |
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Country where you live |
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Passport information |
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Passport number |
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Issuance date |
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Expiration date |
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City where you boarded |
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Telephone number |
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Email address |
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Signature |
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Date |
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Legend:
= mandatory
= optional
QUESTIONS
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Form I-94W/ESTA Current Version |
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Form I-94W/ESTA Revised Version |
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Communicable disease, physical or mental disorder, drug abuser or addict? |
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Disease of public health significance: Chancroid, Gonorrhea, Granuloma inguinale, Infectious Leprosy, Infectious Syphilis, Lymphogranuloma venereum, Active Tuberculosis? |
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Arrested/convicted for offense/crime involving moral turpitude or violation related to controlled substance; arrested/convicted for two or more offenses for which aggregate sentence to confinement was five years or more; controlled substance trafficker, or seeking entry to engage in criminal/immoral activities? |
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Arrested, convicted of a crime for serious damage to property, serious harm to another person/government authority? |
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Have you ever violated any law related to possessing, using, or distributing illegal drugs? |
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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 persecution associated with Nazi Germany or its allies? |
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Do you seek to engage in or have you ever engaged in terrorist activities? |
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Are you seeking to work in the U.S.; or have you ever been excluded or 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? |
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Are you currently seeking employment in the United States or you were previously employed in the United States without prior permission from the U.S. government? |
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Have you ever committed fraud or misrepresented yourself or others to obtain, or assist others to obtain, a visa or entry into the United States? |
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Have you ever detained, retained or withheld custody of a child from a U.S. citizen granted custody of the child? |
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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? ________________________
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Have you ever been denied a U.S. visa you applied for with your current or 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? ________________________
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Have you ever asserted immunity from prosecution? |
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Have you ever overstayed a previous period of lawful admission to the United States, even by one day? |
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | AJR |
File Modified | 0000-00-00 |
File Created | 2021-01-27 |