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

OMB No. 1615-0017
Expires 06/30/2018

For DHS Use Only
Received

Returned Trans. Out

Trans. In

Completed

Fee Stamp

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Action by the Department of Homeland Security
Ground of Inadmissibility

INA 212(a)(1)
INA 212(a)(2)
INA 212(a)(3)
INA 212(a)(4)
INA 212(a)(6)
INA 212(a)(8)

Action Stamp

INA 212(a)(9)

INA 212(a)(10)
Other:

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

Benefits Category:

Nonimmigrant other than T or U nonimmigrant/Advance Permission
under INA 212(d)(3)(A) and 8 CFR 212.4
T Nonimmigrant/Advance Permission under INA 212(d)(3) and
8 CFR 212.16
T Nonimmigrant/Waiver under INA 212(d)(13) and 8 CFR 212.16

INA 212(a)(9)

U Nonimmigrant/Waiver under INA 212(d)(14) and 8 CFR 212.17
U Nonimmigrant/Advance Permission under INA 212(d)(3)(A) and
8 CFR 212.17

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.

Volag Number
(if any)

Attorney State Bar Number
(if applicable)

Attorney or Accredited Representative
USCIS Online Account 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 the Immigration and Nationality Act (INA)
section 212(d)(3)(A)(ii), section 212(d)(13), or section
212(d)(14).
I am seeking this permission so that I may obtain (select only
one box):
1.

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

2.

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

Form I-192 12/23/16 N

Part 2. Information About You
Your Full Name
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name

Page 1 of 11

Part 2. Information About You (continued)

Mailing Address
10.a. In Care Of Name (if any)

Other Names Used (if any)
Provide all other names you have ever used, including aliases,
maiden name, and nicknames. If you need extra space to
complete this section, use the space provided in Part 8.
Additional Information.
2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)

10.b. Street Number
and Name
10.c.

Apt.

Ste.

Flr.

10.d. City or Town

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10.e. State

2.c. Middle Name

10.f. ZIP Code

10.g. Province

10.h. Postal Code

3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)

10.i. Country

3.c. Middle Name

Safe Mailing Address

Other Information
4.

Alien Registration Number (A-Number) (if any)
► A-

5.

USCIS Online Account Number (if any)
►

6.

Date of Birth (mm/dd/yyyy)

7.

Gender

Male

Place of Birth
8.a. City or Town

Female

If you are a T or U visa applicant, and do not want U.S.
Citizenship and Immigration Services (USCIS) to send notices
about this application to your home, you may provide a safe
mailing address.
11.a. In Care Of Name (if any)

11.b. Organization Name (if applicable)

11.c. Street Number
and Name
11.d.

Apt.

Ste.

Flr.

11.e. City or Town
8.b. State or Province
11.f. State
8.c. Country

11.g. ZIP Code

11.h. Province
11.i. Postal Code

9.

Country of Citizenship or Nationality

Form I-192 12/23/16 N

11.j. Country

Page 2 of 11

Part 2. Information About You (continued)

Physical Address 3
16.a. Street Number
and Name

Address History
Provide physical addresses for everywhere you have lived
during the last five years, whether inside or outside the United
States. Provide your current address first. If you need extra
space to complete this section, use the space provided in Part 8.
Additional Information.

16.b.

Apt.

16.d. State

12.a. Street Number
and Name

16.g. Postal Code

Ste.

12.c. City or Town

16.e. ZIP Code

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16.f. Province

Apt.

Flr.

16.c. City or Town

Physical Address 1 (current address)

12.b.

Ste.

16.h. Country

Flr.

Dates of Residence

12.d. State

12.e. ZIP Code

12.f. Province

17.a. From (mm/dd/yyyy)
17.b. To (mm/dd/yyyy)

12.g. Postal Code

Physical Address 4

12.h. Country

18.a. Street Number
and Name

18.b.

Dates of Residence

13.a. From (mm/dd/yyyy)
13.b. To (mm/dd/yyyy)

14.a. Street Number
and Name
Apt.

Ste.

Flr.

18.c. City or Town

PRESENT

18.d. State

18.e. ZIP Code

18.f. Province

Physical Address 2

14.b.

Apt.

18.g. Postal Code

Ste.

Flr.

18.h. Country

14.c. City or Town
Dates of Residence
14.d. State

14.e. ZIP Code

14.f. Province

19.a. From (mm/dd/yyyy)
19.b. To (mm/dd/yyyy)

14.g. Postal Code
14.h. Country

Dates of Residence
15.a. From (mm/dd/yyyy)
15.b. To (mm/dd/yyyy)

Form I-192 12/23/16 N

Page 3 of 11

Part 2. Information About You (continued)

28.

Travel Information

Location where you filed your application (for example, USCIS
Office or Port-of-Entry).

NOTE: If you are applying for T or U nonimmigrant status and
are in the United States, you may skip Item Numbers 20. - 25.
Location at Which you Plan to Enter the United States (desired
Port-of-Entry)
20.a. City
20.b. State
21.

Date Application Filed (mm/dd/yyyy)

29.a. USCIS Office or U.S. Port-of-Entry

29.b. City or Town

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29.c. State or Province

Name of Port-of-Entry

29.d. Country

22.

How do you plan to travel to the United States?
(For example, by plane, ship, car)

29.e. Receipt Number (if available)
►

23.

When do you plan to enter the United States? (mm/dd/yyyy)

24.

Approximate Length of Stay in the United States

25.

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

30.

Have you EVER been in the United States for a period of
six months or more?
Yes
No
If you answered "Yes" to Item Number 30., 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 8. Additional
Information.

31.

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 31., provide the
information requested in Item Numbers 32.a. - 32.c.

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 8. Additional
Information to provide the answers to Item Numbers
32.a. - 32.c. for each of your additional applications or petitions.

Immigration and Criminal History
26.

Do you believe that you may be inadmissible to the
United States?
Yes

No

If you answered "Yes" to Item Number 26., explain the
reasons why you believe, according to the best of your
knowledge, that you may be inadmissible in Part 8.
Additional Information. If you were told that you are
inadmissible, provide the reason you were given.
27.

Have you previously filed an application for advance
permission to enter the United States as a nonimmigrant?
Yes

No

32.a. Type of Application or Petition Filed

32.b. Location Where You (or the Other Person) Filed the
Application or Petition (for example, USCIS office or
Port-of-Entry);

32.c. Outcome of the Application or Petition (for example,
approved, denied, or is pending).

If you answered "Yes" to Item Number 27., provide the
details in Item Numbers 28. - 29.e. If you need extra
space to complete this section, use the space provided in
Part 8. Additional Information.
Form I-192 12/23/16 N

Page 4 of 11

Part 2. Information About You (continued)
33.

Part 4. Other Information About You

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 33., provide an
explanation the information in the space provided in
Part 8. Additional Information.
34.

Employment History
Provide your employment history for the last five years,
whether inside or outside the United States. Provide the most
recent employment first. If you need extra space to complete
this section, use the space provided in Part 8. Additional
Information.

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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?
Yes

No

If you answered "Yes" to Item Number 34., describe the
incidents in detail and include all offenses where impaired
driving may have been an issue in the space provided in
Part 8. Additional Information.

Employer 1 (current or most recent)
1.

Name of Employer or Company

Address of Employer or Company
2.a. Street Number
and Name
2.b.

Apt.

Ste.

Flr.

2.c. City or Town

Part 3. Biographic Information

2.d. State

1.

2.f.

Ethnicity (Select only one box)

2.e. ZIP Code

Province

Hispanic or Latino

2.g. Postal Code

Not Hispanic or Latino
2.

2.h. Country

Race (Select all applicable boxes)

American Indian or Alaska Native
Asian

3.

Your Occupation

Black or African American

Native Hawaiian or Other Pacific Islander
White

4.a. From (mm/dd/yyyy)

3.

Height

4.

Weight

5.

Eye Color (Select only one box)

6.

Dates of Employment

Feet

Inches

4.b. To (mm/dd/yyyy)

Pounds

Black

Blue

Brown

Gray

Green

Hazel

Maroon

Pink

Unknown/Other

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

Black

Blond

Brown

Gray

Red

Sandy

White

Unknown/Other

Form I-192 12/23/16 N

Page 5 of 11

Part 4. Other Information About You (continued)

14.

Current City or Town of Residence (if living)

15.

Current Country of Residence (if living)

Employer 2
5.

Name of Employer or Company

Address of Employer or Company

Information About Your Father

6.a. Street Number
and Name

Father's Legal Name

6.b.

Apt.

Ste.

6.c. City or Town
6.d. State

16.a. Family Name
(Last Name)
16.b. Given Name
(First Name)

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Flr.

6.e. ZIP Code

16.c. Middle Name

Father's Name at Birth (if different than above)

6.f.

Province

6.g. Postal Code
6.h. Country

17.a. Family Name
(Last Name)
17.b. Given Name
(First Name)

17.c. Middle Name

7.

Your Occupation

Dates of Employment

8.a. From (mm/dd/yyyy)
8.b. To (mm/dd/yyyy)

18.

Date of Birth (mm/dd/yyyy)

19.

City or Town of Birth

20.

Country of Birth

21.

Current City or Town of Residence (if living)

22.

Current Country of Residence (if living)

Information About Your Parents
Information About Your Mother
Mother's Legal Name
9.a. Family Name
(Last Name)
9.b. Given Name
(First Name)

Information About Your Marital History
23.

What is your current marital status?

9.c. Middle Name

Single, Never Married

Mother's Name at Birth (if different than above)

Widowed

10.a. Family Name
(Last Name)
10.b. Given Name
(First Name)

Marriage Annulled

10.c. Middle Name
11.

Date of Birth (mm/dd/yyyy)

12.

City or Town of Birth

13.

Country of Birth

Form I-192 12/23/16 N

24.

Married

Divorced

Legally Separated
Other

How many times have you been married (including
annulled marriages and marriages to the same person)?
►

Page 6 of 11

Part 4. Other Information About You (continued)
Information About Your Current Marriage
(including if you are legally separated)
If you are currently married, provide the following information
about your current spouse.
Current Spouse's Legal Name
25.a. Family Name
(Last Name)
25.b. Given Name
(First Name)
25.c. Middle Name
26.

28.

If you have been married before, whether in the United States or
in any other country, provide the information requested in Item
Numbers 31.a. - 36.c. about your prior marriage. If you have
had more than one previous marriage, use the space provided in
Part 8. Additional Information to provide the answers to Item
Numbers 31.a. - 36.c. for each additional marriage.
Prior Spouse's Legal Name (provide family name before
marriage)

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31.a. Family Name
(Last Name)
31.b. Given Name
(First Name)

A-Number (if any)

► A-

27.

Information About Prior Marriages (if any)

31.c. Middle Name
32.

Prior Spouse's Date of Birth (mm/dd/yyyy)

33.

Date of Marriage to Prior Spouse (mm/dd/yyyy)

Current Spouse's Date of Birth (mm/dd/yyyy)

Date of Marriage to Current Spouse (mm/dd/yyyy)

Place of Marriage to Prior Spouse

Current Spouse's Place of Birth
29.a. City or Town

34.a. City or Town

34.b. State or Province

29.b. State or Province

34.c. Country

29.c. Country

35.

Date Marriage with Prior Spouse Legally Ended
(mm/dd/yyyy)

Place of Marriage to Current Spouse
30.a. City or Town

Place Where Marriage with Prior Spouse Legally Ended
36.a. City or Town

30.b. State or Province
36.b. State or Province
30.c. Country
36.c. Country

Form I-192 12/23/16 N

Page 7 of 11

I understand that DHS 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:

Part 5. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature
NOTE: Read the Penalties section of the Form I-192
Instructions before completing this section.

1) I reviewed and understood all of the information
contained in, and submitted with, my application; and

Applicant's Statement

2) All of this information was complete, true, and correct
at the time of filing.

NOTE: Select the box for either Item Number 1.a. or 1.b. If
applicable, select the box for Item Number 2.

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1.a.

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

1.b.

The interpreter named in Part 6. read to me every
question and instruction on this application and my
answer to every question in

Applicant's Signature

,

a language in which I am fluent, and I understood
everything.
2.

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

6.b. Date of Signature (mm/dd/yyyy)

At my request, the preparer named in Part 7.,

,

prepared this application for me based only upon
information I provided or authorized.

Applicant's Contact Information
3.

Applicant's Daytime Telephone Number

4.

Applicant's Mobile Telephone Number (if any)

6.a. Applicant's Signature

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.

Part 6. Interpreter's Contact Information,
Certification, and Signature

Provide the following information about the interpreter.

Interpreter's Full Name

5.

Applicant's Email Address (if any)

1.a. Interpreter's Family Name (Last Name)

1.b. Interpreter's Given Name (First Name)

Applicant's Declaration and Certification
Copies of any documents I have submitted are exact
photocopies of unaltered, original documents, and I understand
that the U.S. Department of Homeland Security (DHS) may
require that I submit original documents to DHS at a later date.
Furthermore, I authorize the release of any information from
any and all of my records that DHS may need to determine my
eligibility for the immigration benefit that I seek.

2.

Interpreter's Business or Organization Name (if any)

I furthermore authorize release of information contained in this
application, in supporting documents, and in my DHS records,
to other entities and persons where necessary for the
administration and enforcement of U.S. immigration law.

Form I-192 12/23/16 N

Page 8 of 11

Part 6. Interpreter's Contact Information,
Certification, and Signature (continued)

Part 7. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant

Interpreter's Mailing Address

Provide the following information about the preparer.

3.a. Street Number
and Name

Preparer's Full Name

3.b.

Apt.

Ste.

3.c. City or Town
3.d. State
3.f.

Flr.

1.a. Preparer's Family Name (Last Name)

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1.b. Preparer's Given Name (First Name)

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

2.

Preparer's Business or Organization Name (if any)

Preparer's Mailing Address

3.a. Street Number
and Name

Interpreter's Contact Information
4.

3.b.

Apt.

Ste.

Flr.

Interpreter's Daytime Telephone Number

3.c. City or Town

5.

3.d. State

Interpreter's Mobile Telephone Number (if any)

3.f.

6.

3.e. ZIP Code

Province

Interpreter's Email Address (if any)

3.g. Postal Code
3.h. Country

Interpreter's Certification

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

,

which is the same language specified in Part 5., Item Number
1.b., 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 Declaration and
Certification, and has verified the accuracy of every answer.

Preparer's Contact Information

4.

Preparer's Daytime Telephone Number

5.

Preparer's Mobile Telephone Number (if any)

6.

Preparer's Email Address (if any)

Interpreter's Signature
7.a. Interpreter's Signature

7.b. Date of Signature (mm/dd/yyyy)

Form I-192 12/23/16 N

Page 9 of 11

Part 7. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant
(continued)
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.

7.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.

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NOTE: If you are an attorney or accredited
representative, you may need to submit a completed
Form G-28, Notice of Entry of Appearance as
Attorney or Accredited Representative, or Form
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 Declaration and 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.a. Preparer's Signature

8.b. Date of Signature (mm/dd/yyyy)

Form I-192 12/23/16 N

Page 10 of 11

5.a. Page Number

Part 8. 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. Type or print your name and A-Number (if any)
at the top of each sheet; indicate the Page Number, Part
Number, and Item Number to which your answer refers; and
sign and date each sheet.

1.c. Middle Name

5.c. Item Number

5.d.

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1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

2.

5.b. Part Number

A-Number (if any) ► A-

3.a. Page Number

3.b. Part Number

6.a. Page Number

6.b. Part Number

6.c. Item Number

7.b. Part Number

7.c. Item Number

6.d.

3.d.

4.a. Page Number

3.c. Item Number

4.b. Part Number

4.d.

Form I-192 12/23/16 N

4.c. Item Number

7.a. Page Number

7.d.

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