Form I-94W NonImmigrant Visa Waiver Arrival/Departure Record

Welcome to the
United States

Admission Number

This Space For Official Use Only

00000000000

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

ARRIVAL RECORD Visa Waiver
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.

5 Travel Information
Is your travel to the U.S. occurring in transit to another country?
Address while in the United States
Address Line 1

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 7) and the
Departure Record (Items 10 through 13). 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.

Yes

No

Apartment Number
City

Address Line 2
State

1 Applicant Information
Applicant Name (Please print, ALL CAPS)
Family Name

First (Given) Name

6 U.S. Point of Contact Information
U.S. Point of Contact

Are you known by any other names or aliases?

Yes

No

Other Names/Aliases
Family Name

First (Given) Name

Parents
Family Name

First (Given) Name

Address
Address Line 1

Apartment Number
City

Address Line 2
State
Telephone Number
Country Code/Number

Birth Date (DD/MM/YY)
City of Birth

7 Employment Information
Do you have a curent or previous employer?

Country of Birth

Yes

No

Employer Name
Gender (Male or Female)
Address
Address Line 1

Apartment Number

2 Passport Information
Passport Number

Address Line 2

City

Passport Issuing Country

State/Province/Region

Country

Issuance Date (DD/MM/YY)

Telephone Number
Country Code/Number

Expiration Date (DD/MM/YY)

Country of Citizenship

Job Title

National Identification Number

Government Use Only
Other Citizenship?
Country

Yes

SEE OTHER SIDE

8

No
Passport Number

9
CBP Form I-94W (xx/14)

3 Contact Information
E-mail Address

OMB NO. 1651-0111

Admission Number

Telephone Number
Country Code/Number
Home Address
Address Line 1

00000000000
Apartment Number

Address Line 2

City

State/Province/Region

Country

DEPARTURE RECORD Visa Waiver
10

Family Name (Please print, ALL CAPS)

11

First/Given Name

12

Birth Date (DD/MM/YY)

13

Country of Citizenship

4 Emergency Contact Information
Emergency Contact
Family Name
Telephone Number
Country Code/Number
E-mail Address

CBP Form I-94W English (xx14) DRAFT 3c.indd 1

This Space For Official Use Only

First (Given) Name

CBP Form I-94W (xx/14)
STAPLE HERE

9/22/14 5:03 PM

Do any of the following apply to you? (Answer Yes or No)
A Do you have a physical or mental disorder; or are you a drug abuser or addict;

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

or currently have any of the following diseases:
Chancroid

Lymphogranuloma venereum

Gonorrhea

Syphilis, infectious

Granuloma Inguinale

Active Tuberculosis

Leprosy, infectious
damage to property, or serious harm to another person or government authority?

illegal drugs?

espionage, sabotage, or genocide?

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 stayed in the United States longer than the admission period
granted to you by the U.S. government 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.

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


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

CBP Form I-94W English (xx14) DRAFT 3c.indd 2

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 1651-0111. The estimated average time to
complete this application is 13 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.

9/22/14 5:03 PM