Form I-192 Form I-192 Application for Advance Permission to Enter as Nonimmigr

Application for Advance Permission to Enter
as a Nonimmigrant

USCIS
Form I-192

Department of Homeland Security
U.S. Citizenship and Immigration Services

For
DHS
Use
Only

Received

Returned Trans. Out

Trans. In

Completed

OMB No. 1615-0017
Expires 10/31/2017

Fee Stamp

Action by the Department of Homeland Security

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Granted, subject to revocation at any time, upon the
following terms and conditions:

Date of Action (mm/dd/yyyy)
DD or OIC
Office

To be completed by an attorney or accredited representative (if any).

Select this box if
Form G-28 or
Form G-28I is
attached.

Attorney State Bar Number
(if applicable)

Volag Number

Attorney or Accredited Representative
USCIS ELIS Online Number (if any)

► START HERE - Type or print in black ink.

Part 1. Application Type

I am applying to the Secretary of Homeland Security for permission to enter the United States temporarily under the provisions of
section 212(d)(3)(A)(ii), section 212(d)(13), or section 212(d)(14) of the Immigration and Nationality Act (INA).
I am seeking this permission so that I may obtain (Select only one box):
1.

A.

Admission as a nonimmigrant (other than as a T or U nonimmigrant)

B.

Status as a victim of trafficking (T nonimmigrant status) or a victim of a crime (U nonimmigrant status)

Part 2. Information About You
1.

Family Name (Last Name)

2.

Alien Registration Number (A-Number) (if any) 3. USCIS Online Account Number (if any)
►

5.

A-

Middle Name

4. Date of Birth (mm/dd/yyyy)

►

Place of Birth
City or Town

6.

Given Name (First Name)

State or Province

Country

Country of Citizenship or Nationality

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Part 2. Information About You (continued)
7.

Physical Address
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State
Postal Code

Province

8.

ZIP Code

Country

Provide the addresses where you have resided during the past five years, starting with the last place you lived prior to your
current physical address listed under Item Number 7. If you need extra space to complete this section, use the space provided
in Part 7. Additional Information.

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A. Residence Number 1

Date of Residence From (mm/dd/yyyy)

To (mm/dd/yyyy)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

B. Residence Number 2

Date of Residence From (mm/dd/yyyy)

To (mm/dd/yyyy)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

C. Residence Number 3

To (mm/dd/yyyy)

Date of Residence From (mm/dd/yyyy)
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

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Postal Code

ZIP Code

Country

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Part 2. Information About You (continued)
D. Residence Number 4
Date of Residence From (mm/dd/yyyy)

To (mm/dd/yyyy)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

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Travel Information
9.

Location at which you plan to enter the United States (desired Port-of-Entry)
City
State

10. Name of Port-of-Entry

11. How do you plan to travel to the United States? (For example, by plane, ship, car) 12. When do you plan to enter the United States?
(mm/dd/yyyy)

13. Approximate Length of Stay in the United States

14. What is the purpose of your stay in the United States? Explain fully below.

Immigration and Criminal History

Yes
No
15. Do you believe that you may be inadmissible to the United States?
If you answered "Yes," explain the reasons why you believe, according to the best of your knowledge, that you may be
inadmissible in Part 7. Additional Information. If you were told that you are inadmissible, provide the reason you were given.
16. Have you previously filed an application for advance permission to enter the United States as a
nonimmigrant?

Yes

No

If you answered “Yes,” provide the details in Items A. - C. in Item Number 17. If you need extra space to complete this section,
use the space provided in Part 7. Additional Information.
17. A. Date Application Filed (mm/dd/yyyy)
B. Location where you filed your application (For example, U.S. Citizenship and Immigration Services (USCIS) Office or
Port-of-Entry)
USCIS Office or U.S. Port-of-Entry
City or Town
State or Province
Country

C. Receipt Number (if available) ►
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Part 2. Information About You (continued)
NOTE: If you are an applicant for T nonimmigrant status or a petitioner for U nonimmigrant status, you do not need to
answer Item Numbers 18. - 21.
Yes

18. Have you EVER been in the United States for a period of six months or more?

No

If you answered “Yes,” provide the dates you were in the United States (from and to) and your immigration status at the time of
entry into the United States in the space provided in Part 7. Additional Information.
19. Have you EVER filed an application or petition for immigration benefits with the U.S. Government, or has
one ever been filed on your behalf?

Yes

No

If you answered “Yes” to Item Number 19. provide the information in the space provided in Part 7. Additional Information.
NOTE: If you (or somebody else on your behalf) have filed multiple applications or petitions for immigration benefits with the
U.S. Government, use the space provided in Part 7. to also provide the following information:

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A. Type of application or petition filed;

B. Location where you (or the other person) filed the application or petition (for example, USCIS office or Port-of-Entry);
C. Outcome of the application or petition (for example, approved, denied, or is pending)

20. Have you EVER been denied or refused an immigration benefit by the U.S. Government, or had a benefit
revoked or terminated (including but not limited to visas)?

Yes

No

If you answered “Yes” to Item Number 20., provide the information in the space provided in Part 7. Additional Information.
21. Have you EVER, in or outside the United States, been arrested, cited, charged, indicted, fined, convicted,
or imprisoned for breaking or violating any law or ordinance, excluding minor traffic violations? If you
answered “Yes,” describe the incidents in detail and include all offenses where impaired driving may have
been an issue in the space provided in Part 7. Additional Information.

Yes

No

Part 3. Biographic Information
1.

Ethnicity (Select only one box)

2.

Race (Select all applicable boxes)
White

Asian

Black or African
American

3.

Height Feet

5.

Eye Color (Select only one box)
Black

6.

Hispanic or Latino

4.

Inches

Blue

Brown

Not Hispanic or Latino

American Indian or
Alaska Native

Native Hawaiian or
Other Pacific Islander

Weight Pounds

Gray

Green

Hazel

Maroon

Pink

Unknown/
Other

Hair Color (Select only one box)
Bald
(No hair)

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Black

Blond

Brown

Gray

Red

Sandy

White

Unknown/
Other

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Part 4. Applicant's Statement, Contact Information, Certification, and Signature
NOTE: Read the information on penalties in the Penalties section of the Form I-192 Instructions before completing this part.
NOTE: Select the box for either either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2.
1.

Applicant's Statement Regarding the Interpreter
A.

I can read and understand English, and have read and understand every question and instruction on this application and
my answer to every question.

B.

The interpreter named in Part 5. read to me every question and instruction on this application, and my answer to
every question in
am fluent, and I understood everything.

2.

, a language in which I

Applicant's Statement Regarding the Preparer

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At my request, the preparer named in Part 6.,
prepared this application for me based only upon information I provided or authorized.

,

Applicant's Contact Information
3.

Applicant's Daytime Telephone Number

5.

Applicant's Email Address (if any)

4.

Applicant's Mobile Telephone Number (if any)

Applicant’s Certification

Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS may
require that I submit original documents to USCIS at a later date. Furthermore, I authorize the release of any information from any of
my records that USCIS may need to determine my eligibility for the immigration benefit I seek.
I further authorize release of information contained in this application, in supporting documents, and in my USCIS records to other
entities and persons where necessary for the administration and enforcement of U.S. immigration laws.
I understand that USCIS may require me to appear for an appointment to take my biometrics (fingerprints, photograph, and/or
signature) and, at that time, if I am required to provide biometrics, I will be required to sign an oath reaffirming that:
1) I reviewed and provided or authorized all of the information in my application;
2) I understood all of the information contained in, and submitted with, my application; and
3) All of this information was complete, true, and correct at the time of filing.

I certify, under penalty of perjury, that I provided or authorized all of the information in my application, I understand all of the
information contained in, and submitted with, my application, and that all of this information is complete, true, and correct.

Applicant's Signature
6.

Applicant's Signature

Date of Signature (mm/dd/yyyy)

NOTE TO ALL APPLICANTS: If you do not completely fill out this application or fail to submit required documents listed in the
Instructions, USCIS may deny your application.

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Part 5. Interpreter's Contact Information, Certification, and Signature
Provide the following information about the interpreter.

Interpreter's Full Name
1.

Interpreter's Family Name (Last Name)

2.

Interpreter's Business or Organization Name (if any)

Interpreter's Given Name (First Name)

Interpreter's Mailing Address
3.

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Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

Interpreter's Contact Information
4.

Interpreter's Daytime Telephone Number

6.

Interpreter's Email Address (if any)

5.

Interpreter's Mobile Telephone Number (if any)

Interpreter's Certification

I certify, under penalty of perjury, that:
I am fluent in English and

, which is the same language specified

in Part 4., Item B. in Item Number 1., and I have read to this applicant in the identified language every question and instruction on
this application and his or her answer to every question. The applicant informed me that he or she understands every instruction,
question, and answer on the application, including the Applicant's Certification, and has verified the accuracy of every answer.

Interpreter's Signature
7.

Interpreter's Signature

Form I-192 10/21/15 N

Date of Signature (mm/dd/yyyy)

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Part 6. Contact Information, Declaration, and Signature of the Person Preparing this Application, if
Other Than the Applicant
Provide the following information about the preparer.

Preparer's Full Name
1.

Preparer's Family Name (Last Name)

2.

Preparer's Business or Organization Name (if any)

Preparer's Given Name (First Name)

Preparer's Mailing Address
3.

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Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

6.

Preparer's Email Address (if any)

5.

Preparer's Mobile Number (if any)

Preparer's Statement
7.

A.

I am not an attorney or accredited representative but have prepared this application on behalf of the applicant and with
the applicant's consent.

B.

I am an attorney or accredited representative and my representation of the applicant in this case
extends does not extend beyond the preparation of this application.

NOTE: If you are an attorney or accredited representative whose representation extends beyond preparation of this
application, you may be obliged to submit a completed Form G-28, Notice of Entry of Appearance as Attorney or
Accredited Representative, or G-28I, Notice of Entry of Appearance as Attorney In Matters Outside the Geographical
Confines of the United States, with this application.

Preparer's Certification
By my signature, I certify, under penalty of perjury, that I prepared this application at the request of the applicant. The applicant then
reviewed this completed application and informed me that he or she understands all of the information contained in, and submitted
with, his or her application, including the Applicant's Certification, and that all of this information is complete, true, and correct. I
completed this application based only on information that the applicant provided to me or authorized me to obtain or use.

Preparer's Signature
8.

Preparer's Signature

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Date of Signature (mm/dd/yyyy)

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Part 7. Additional Information
If you need extra space to provide any additional information within this application, use the space below. If you need more space
than what is provided, you may make copies of this page to complete and file with this application or attach a separate sheet of paper.
Include your name and A-Number (if any) at the top of every sheet; indicate the Page Number, Part Number, and Item Number to
which your answer refers; and sign and date each sheet.
1.

Family Name (Last Name)

2.

A-Number (if any)

3.

A. Page Number
D.

4.

5.

A. Page Number
D.

6.

Middle Name

► AB. Part Number

C. Item Number

B. Part Number

C. Item Number

B. Part Number

C. Item Number

B. Part Number

C. Item Number

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A. Page Number
D.

Given Name (First Name)

A. Page Number
D.

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