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 04/30/2021

For DHS Use Only
Received

Returned Trans. Out

Fee Stamp

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Trans. In

Completed

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 04/09/19

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 10

Part 2. Information About You (continued)
Other Names Used (if any)

Mailing Address
10.a. In Care Of Name (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.

10.b. Street Number
and Name

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

10.d. City or Town

2.c. Middle Name

10.g. Province

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

10.h. Postal Code

Apt.

Ste.

Flr.

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10.f. ZIP Code

10.i. Country

Safe Mailing Address

Other Information

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

5.

10.c.

10.e. State

3.c. Middle Name

4.

(USPS ZIP Code Lookup)

USCIS Online Account Number (if any)

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)

►
6.

Date of Birth (mm/dd/yyyy)

7.

Gender

Place of Birth

Male

Female

8.a. City or Town

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
8.c. Country

11.f. State

11.g. ZIP Code

11.h. Province
11.i. Postal Code

9.

Country of Citizenship or Nationality

Form I-192 04/09/19

11.j. Country

Page 2 of 10

Part 2. Information About You (continued)
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 7.
Additional Information.

Physical Address 3
16.a. Street Number
and Name
16.b.

Apt.

16.d. State

12.a. Street Number
and Name

16.g. Postal Code

Ste.

Flr.

12.c. City or Town
12.d. State
12.f. Province
12.g. Postal Code
12.h. Country

16.h. Country

Dates of Residence

12.e. ZIP Code

17.a. From (mm/dd/yyyy)
17.b. To (mm/dd/yyyy)
Physical Address 4

18.a. Street Number
and Name

Dates of Residence

18.b.

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

18.c. City or Town

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

18.d. State

Physical Address 2

18.f. Province

14.a. Street Number
and Name

18.g. Postal Code

14.b.

Apt.

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.

Ste.

Flr.

14.c. City or Town
14.d. State

Apt.

Ste.

Flr.

18.e. ZIP Code

18.h. Country

Dates of Residence
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 04/09/19

Page 3 of 10

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

Date Application Filed (mm/dd/yyyy)

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

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29.b. City or Town

29.c. State or Province

21.

Name of Port-of-Entry

22.

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

29.d. Country

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 7. 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 7. 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 7.
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 7. Additional Information.
Form I-192 04/09/19

Page 4 of 10

Part 2. Information About You (continued)

Dates of Employment

33.

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

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 7. Additional Information.
34.

4.b. To (mm/dd/yyyy)
Employer 2
5.

Name of Employer or Company

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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 7. Additional Information.

Part 3. Other Information About You

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

Apt.

Ste.

Flr.

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

6.e. ZIP Code

Province

6.g. Postal Code
6.h. Country

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 7. Additional
Information.

7.

Employer 1 (current or most recent)

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

1.

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

Name of Employer or Company

Your Occupation

Dates of Employment

Address of Employer or Company

Information About Your Parents

2.a. Street Number
and Name

Information About Your Mother

2.b.

Apt.

Ste.

Flr.

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

2.e. ZIP Code

Province

2.g. Postal Code

Mother's Legal Name
9.a. Family Name
(Last Name)
9.b. Given Name
(First Name)
9.c. Middle Name
Mother's Name at Birth (if different than above)

2.h. Country

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

3.

10.c. Middle Name

Your Occupation

Form I-192 04/09/19

Page 5 of 10

Part 3. Other Information About You (continued)

24.

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

11.

Date of Birth (mm/dd/yyyy)

12.

City or Town of Birth

13.

Country of Birth

14.

Current City or Town of Residence (if living)

Current Spouse's Legal Name

Current Country of Residence (if living)

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

15.

►

Information About Your Current Marriage
(including if you are legally separated)
If you are currently married, provide the following information
about your current spouse.

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25.c. Middle Name

Information About Your Father

26.

Father's Legal Name

A-Number (if any)

► A-

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

27.

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

16.c. Middle Name

28.

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

Father's Name at Birth (if different than above)
17.a. Family Name
(Last Name)
17.b. Given Name
(First Name)

Current Spouse's Place of Birth

17.c. Middle Name

29.b. State or Province

29.a. City or Town

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)

29.c. Country

Place of Marriage to Current Spouse
30.a. City or Town
30.b. State or Province
30.c. Country

Information About Your Marital History
23.

What is your current marital status?
Single, Never Married
Widowed

Divorced

Legally Separated

Marriage Annulled

Form I-192 04/09/19

Married
Other

Page 6 of 10

Part 3. Other Information About You (continued)
Information About Prior Marriages (if any)
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 7. Additional Information to provide the answers to Item
Numbers 31.a. - 36.c. for each additional marriage.

Part 4. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature
NOTE: Read the Penalties section of the Form I-192
Instructions before completing this section.

Applicant's Statement

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Prior Spouse's Legal Name (provide family name before
marriage)
31.a. Family Name
(Last Name)
31.b. Given Name
(First Name)

NOTE: Select the box for either Item Number 1.a. or 1.b. If
applicable, select the box for Item Number 2.
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 5. read to me every
question and instruction on this application and my
answer to every question in

31.c. Middle Name
32.
33.

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

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

2.

Place of Marriage to Prior Spouse

34.b. State or Province
34.c. Country

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

Place Where Marriage with Prior Spouse Legally Ended
36.a. City or Town
36.b. State or Province
36.c. Country

At my request, the preparer named in Part 6.,
,

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

34.a. City or Town

35.

,

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

Applicant's Contact Information

3.

Applicant's Daytime Telephone Number

4.

Applicant's Mobile Telephone Number (if any)

5.

Applicant's Email Address (if any)

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.
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 04/09/19

Page 7 of 10

Part 4. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature (continued)
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.

Interpreter's Contact Information
4.

Interpreter's Daytime Telephone Number

5.

Interpreter's Mobile Telephone Number (if any)

6.

Interpreter's Email Address (if any)

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Applicant's Signature

Interpreter's Certification

6.a. Applicant's Signature

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

6.b. 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.

Part 5. Interpreter's Contact Information,
Certification, and Signature

Provide the following information about the interpreter.

Interpreter's Full Name

,

which is the same language specified in Part 4., 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.

Interpreter's Signature

7.a. Interpreter's Signature

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

1.a. Interpreter's Family Name (Last Name)
1.b. Interpreter's Given Name (First Name)
2.

Interpreter's Business or Organization Name (if any)

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
Interpreter's Mailing Address

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

3.a. Street Number
and Name

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

3.b.

Apt.

Ste.

Flr.
2.

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

Preparer's Business or Organization Name (if any)

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

Form I-192 04/09/19

Page 8 of 10

Part 6. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant
(continued)
Preparer's Mailing Address
3.a. Street Number
and Name
3.b.

Apt.

3.f.

Province

3.g. Postal Code
3.h. Country

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.

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Ste.

Flr.

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

Preparer's Certification

3.e. ZIP Code

Preparer's Signature

8.a. Preparer's Signature

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

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)

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.
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.

Form I-192 04/09/19

Page 9 of 10

5.a. Page Number

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. 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.

5.b. Part Number

5.c. Item Number

5.d.

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

1.c. Middle Name
2.

A-Number (if any) ► A-

3.a. Page Number

3.d.

4.a. Page Number

4.d.

Form I-192 04/09/19

3.b. Part Number

3.c. Item Number

6.a. Page Number

6.b. Part Number

6.c. Item Number

7.b. Part Number

7.c. Item Number

6.d.

4.b. Part Number

4.c. Item Number

7.a. Page Number

7.d.

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