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

Welcome to the United States
I-94W Nonimmigrant Visa Waiver Arrival/Departure Record
ARRIVAL RECORD Visa Waiver
Instructions

OMB NO. 1651-0111

Admission Number

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.

This Space For Official Use Only

00000000000

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.

1 Applicant Information

3 Contact Information

Applicant Name (Please print, ALL CAPS)
Family Name

Are you known by any other names or aliases?
Other Names/Aliases
Family Name

E-mail Address
First (Given) Name

Yes

Telephone Number
Country Code/Number

No

First (Given) Name

Parents
Family Name

Home Address
Address Line 1

First (Given) Name

Apartment Number

Address Line 2

City

State/Province/Region

Country

Birth Date (DD/MM/YY)

4 Emergency Contact Information

City of Birth

Emergency Contact
Family Name

First (Given) Name

Country of Birth
Telephone Number
Country Code/Number

Gender (Male or Female)

E-mail Address

2 Passport Information
Passport Number

5 Travel Information
Passport Issuing Country

Is your travel to the U.S. occurring in transit to another country?

Issuance Date (DD/MM/YY)

Address while in the United States
Address Line 1

Expiration Date (DD/MM/YY)

Address Line 2

Country of Citizenship

Yes

No

Apartment Number
City

State

National Identification Number

Other Citizenship?
Country

Yes

SEE OTHER SIDE

No
Passport Number

CBP Form I-94W (xx15)
OMB NO. 1651-0111

Admission Number

This Space For Official Use Only

00000000000
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

CBP Form I-94W (xx15)
STAPLE HERE

Do any of the following apply to you? (Answer Yes or No)

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

1 Do you currently have any of the following diseases (communicable diseases

Yes

No

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

Yes

No

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

Yes

No

4 Do you seek to engage in or have you ever engaged in terrorist activities,

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

Yes

No

are specified in section 361(b) of the Public Health Service Act)?

Address
Address Line 1

Cholera
Apartment Number

Diphtheria
Tuberculosis, infectious

Address Line 2

City

Plague

V
 iral Hemorrhagic Fevers, including Ebola,
Lassa, Marburg, Crimean-Congo
S
 evere acute respiratory illnesses capable
of transmission to other persons and
likely to cause mortality.

Smallpox
State

Yellow Fever

Telephone Number
Country Code/Number

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

illegal drugs?

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

Yes

No

espionage, sabotage, or genocide?

Employer Name
Address
Address Line 1

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

Apartment Number

Address Line 2

City

State/Province/Region

Country

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,

Telephone Number
Country Code/Number
Job Title

when? _____________________ where? ___________________________________

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

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.

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. If you have any comments regarding this
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

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

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Date