Form CBP Form I-95 CBP Form I-95 Crewman's Landing Permit

OMB No. 1651-0114
Expires 06/30/2018

DEPARTMENT OF HOMELAND SECURITY

U.S. Customs and Border Protection

FIN or “A” No.

CREWMAN’S LANDING PERMIT
Family Name
Home Address

Given Name

Initial

Address in United States

Hair

Eyes

Ht.

Wt.

Date of Birth
Place of Birth
Passport Number/Nationality
Arrived by

Air

Sea
CBP Form I-95 (02/12)

CREWMAN’S LANDING PERMIT
Department of Homeland Security – U.S. Customs and Border Protection
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, specifically the Immigration and Nationality Act (8 U.S.C. 1282) and 8 CFR 251.1(c), 252.1(e) and 264.1.
The purpose of this collection is to provide for the application and approval of alien crew members for
permission to temporarily land in the United States. The information solicited on this form will be used to assist
DHS in determining your eligibility for such privileges and may be made available to other government agencies
for law enforcement purposes, as necessary. All alien crew members seeking to land in the U.S., unless
otherwise excepted, must provide this information. Failure to provide this information may result in a denial to
land in 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 and
an expiration date. The control number for this collection is 1651-0114. The estimated average time to complete
this application is 5 minutes. If you have any comments regarding the burden estimate you can write to U.S.
Customs and Border Protection, Office of Regulations and Rulings, 799 9th Street, NW., Washington DC 20229.

CBP Form I-95 (02/12)
Arrival Date

Place of Arrival

CBP Officer Signature

By accepting this conditional permit to land, the holder agrees to all the
conditions incident to the issuance thereof and to deportation from the United
States in accordance with the provisions of section 252(b) of the Immigration and
Nationality Act.

CBP Form I-95 (02/12)