Form I-94 Arrival/Departure Record

DEPARTMENT OF HOMELAND SECURITY
U.S. Customs and Border Protection

OMB No. 1651-0111

Welcome to the United States
I-94 Arrival/Departure Record
Instructions
This form must be completed by all persons except U.S. Citizens, returning resident aliens,
aliens with immigrant visas, and Canadian Citizens visiting or in transit.
Type or print legibly with pen in ALL CAPITAL LETTERS. Use English. Do not write on the
back of this form.
This form is in two parts. Please complete both the Arrival Record (Items 1 through 17) and
the Departure Record (Items 18 through 21).
When all items are completed, present this form to the CBP Officer.
Item 9 - 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.
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.

CBP Form I-94 (05/08)

OMB No. 1651-0111

Arrival Record
Admission Number

000000000 00

1. Family Name
2. First (Given) Name

3. Birth Date (DD/MM/YY)

4. Country of Citizenship

5. Sex (Male or Female)

6. Passport Issue Date (DD/MM/YY)

7. Passport Expiration Date (DD/MM/YY)

8. Passport Number

9. Airline and Flight Number

10. Country Where You Live

11. Country Where You Boarded

12. City Where Visa Was Issued

13. Date Issued (DD/MM/YY)

14. Address While in the United States (Number and Street)
15. City and State
16. Telephone Number in the U.S. Where You Can be Reached
17. Email Address
CBP Form I-94 (05/08)

DEPARTMENT OF HOMELAND SECURITY
U.S. Customs and Border Protection

OMB No. 1651-0111

Departure Record
Admission Number

000000000 00

18. Family Name
19. First (Given) Name

20. Birth Date (DD/MM/YY)

21. Country of Citizenship

CBP Form I-94 (05/08)
See Other Side

STAPLE HERE

This Side For Government Use Only
Primary Inspection

Applicant’s
Name
Date
Referred

Time

Insp. #

Reason Referred

I-94 Back
11” h x 4.5”w
Fonts:
Arial, Times

212A

PP

Visa

Parole

L/O

TWOV

Other

Secondary Inspection
End Secondary
Time

Insp. #

Disposition

22. Occupation

23. Waivers

24. CIS A Number

25. CIS FCO

26. Petition Number

27. Program Number

28.

29.

A-

Bond

Prospective Student

30. Itinerary/Comments

31. TWOV Ticket Number

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 8 minutes per respondent. If you have any comments regarding the
burden estimate you can write to U.S. Customs and Border Protection, Asset Management, 1300
Pennsylvania Avenue, NW, Washington DC 20229

Warning A nonimmigrant who accepts unauthorized employment is subject to deportation.

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
Students planning to reenter the U.S. within 30 days to return to the same school, see “ArrivalDeparture” on page 2 of Form I-20 prior to surrendering this permit.
Record of Changes

Port:
Date:
Carrier:
Flight No./ Ship Name:

Departure Record