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 10/31/2023

For DHS Use Only
Received

Returned Trans. Out

Fee Stamp

DRAFT
NOT FOR
PRODUCTION
10/31/2023
Trans. In

Completed

Action by the Department of Homeland Security
Ground of Inadmissibility

INA 212(a)(1)

INA 212(a)(9)

INA 212(a)(2)

INA 212(a)(10)

INA 212(a)(3)

Other:

INA 212(a)(4)

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

Action Stamp

Benefits Category:

INA 212(a)(6)

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)(7)

U Nonimmigrant/Waiver under INA 212(d)(14) and 8 CFR 212.17

INA 212(a)(8)

U Nonimmigrant/Advance Permission under INA 212(d)(3)(A) and
8 CFR 212.17
Nonimmigrant other than T or U nonimmigrant/Advance Permission
under INA 212(d)(3)(A) and 8 CFR 212.4

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), 212(d)(13), or 212(d)(14).
1.

I am seeking this permission so that I may obtain (select only one box):
Status as a victim of trafficking (T nonimmigrant status) or
a victim of qualifying criminal activity (U nonimmigrant status).
Admission as a nonimmigrant (other than as a T or U nonimmigrant).

If filing this form concurrently with a USCIS Form I-914/I-914A or Form I-918/I-918A (T or U nonimmigrant, respectively) or in
relation to one that you previously filed, you should complete Item Numbers 1. - 10. and then skip to Item Number 26.

Form I-192 Edition 07/20/21

Page 1 of 9

Part 2. Information About You
1.

Your Full Legal Name (Do not provide a nickname)
Family Name (Last Name)

2.

Given Name (First Name)

Middle Name (if applicable)

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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 6. Additional Information.
Family Name (Last Name)

Given Name (First Name)

Middle Name (if applicable)

Other Information
3.

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

4.

USCIS Online Account Number (if any)
►

5.

Date of Birth (mm/dd/yyyy)

6.

Place of Birth
City or Town

State or Province

Country

7.

Country of Citizenship or Nationality

8.

Gender
Male

9.

Female

Another Gender Identity

Mailing Address (Safe address, if applicable)
Please provide an address where you can safely receive correspondence from USCIS.
In Care Of Name (if any)

Street Number and Name

Apt. Ste. Flr.

Number

City or Town

State

ZIP Code

Province

Form I-192 Edition 07/20/21

Postal Code

Country

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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 6. Additional
Information.
10.

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Physical Address 1 (current address)
Street Number and Name

Apt.Ste. Flr.

Number

City or Town

State

ZIP Code

Street Number and Name

Apt.Ste. Flr.

Number

City or Town

State

ZIP Code

Province

Postal Code

Country

Dates of Residence

From (mm/dd/yyyy)

11.

To (mm/dd/yyyy)

Physical Address 2

Province

Postal Code

Country

Dates of Residence

From (mm/dd/yyyy)

To (mm/dd/yyyy)

Information About Your Marital History
12.

What is your current marital status?
Single, Never Married

Married

Divorced

Widowed

Legally Separated

Marriage Annulled

Other
13.

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

Information About Your Current Marriage (including if you are legally separated)
If you are currently married, provide the following information about your current spouse.
14.

Current Spouse's Legal Name
Family Name (Last Name)

15.

Given Name (First Name)

Middle Name (if applicable)

Spouse's Alien Registration Number (A-Number) (if any) ► A-

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Part 2. Information About You (continued)
16.

Date of Birth (mm/dd/yyyy)

18.

Place of Birth

17.

Date of Marriage (mm/dd/yyyy)

City or Town

State or Province

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Country

19.

Place of Marriage
City or Town

State or Province

Country

Information About Prior Marriages (if any)

If you have been married before, anywhere in the world, provide the information requested in Item Numbers 20. - 25. about your
prior marriage. If you have had more than one previous marriage, use the space provided in Part 6. Additional Information to
provide the answers to Item Numbers 20. - 25. for each additional marriage.
20.

Prior Spouse's Legal Name (provide family name before marriage)
Family Name (Last Name)

21.

Date of Birth (mm/dd/yyyy)

23.

Place of Marriage

Given Name (First Name)

22.

Middle Name (if applicable)

Date of Marriage (mm/dd/yyyy)

City or Town

State or Province

Country

24.

Date Marriage Legally Ended (mm/dd/yyyy)

25.

Place Where Marriage Legally Ended
City or Town

State or Province

Country

Immigration and Criminal History
26.

Explain the grounds of inadmissibility that may apply in your case.

Form I-192 Edition 07/20/21

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Part 2. Information About You (continued)
27.

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

Yes

No

If you answered "Yes" to Item Number 27., provide the details in Item Numbers 28. - 29.
If you need extra space to complete this section, use the space provided in Part 6. Additional Information.

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28.

Date Application Filed (mm/dd/yyyy)

29.

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

City or Town

State or Province

Country

Receipt Number (if available) ►
30.

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

Yes

No

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 6. 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?
If you answered "Yes" to Item Number 31., provide the information requested in Item Numbers 32. - 34.

If you have (or somebody else on your behalf has) filed multiple applications or petitions for immigration benefits with the U.S.
Government, use the space provided in Part 6. Additional Information to provide the answers to Item Numbers 32. - 34. for each of
your additional applications or petitions.
32.

Type of application or petition filed

33.

Location the application or petition was filed (for example, USCIS office or Port of Entry)

34.

Outcome of the application or petition (for example, approved, denied, or pending).

35.

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

Yes

No

If you answered "Yes" to Item Number 35., provide an explanation the information in the space provided
in Part 6. Additional Information.
36.

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" to Item Number 36., describe the incidents in detail and include all offenses where
impaired driving may have been an issue in the space provided in Part 6. Additional Information.

Form I-192 Edition 07/20/21

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Part 2. Information About You (continued)
Travel Information
NOTE: If you are applying for T or U nonimmigrant status and are in the United States, you may skip Item Numbers 37. - 43.
Location at Which you Plan to Enter the United States (desired Port of Entry)

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37.

City

38.

State

40.

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

41.

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

42.

Approximate Length of Stay in the United States

43.

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

39.

Name of Port of Entry

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 6. Additional Information.
44.

Employer 1 (current or most recent)
Name of Employer or Company

Address of Employer or Company
Street Number and Name

Apt.Ste. Flr.

Number

City or Town

State

ZIP Code

Province

Postal Code

Country

Your Occupation

Dates of Employment
From (mm/dd/yyyy)

Form I-192 Edition 07/20/21

To (mm/dd/yyyy)

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Part 2. Information About You (continued)
45.

Employer 2
Name of Employer or Company

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Address of Employer or Company
Street Number and Name

Apt.Ste. Flr.

Number

City or Town

State

ZIP Code

Province

Postal Code

Country

Your Occupation

Dates of Employment
From (mm/dd/yyyy)

To (mm/dd/yyyy)

Part 3. Applicant's Statement, Contact Information, Certification, and Signature
Applicant's Contact Information

Provide your daytime telephone number, mobile telephone number (if any), and email address (if any).
1.

Applicant's Daytime Telephone Number

3.

Applicant's Email Address (if any)

2.

Applicant's Mobile Telephone Number (if any)

Applicant's Certification and Signature
I certify, under penalty of perjury, that I provided or authorized all of the responses and information contained in and submitted with
my application, I read and understand or, if interpreted to me in a language in which I am fluent by the interpreter listed in Part 4.,
understood, all of the responses and information contained in, and submitted with, my application, and that all of the responses and the
information is complete, true, and correct. Furthermore, I authorize the release of any information from any and all of my records that
USCIS may need to determine my eligibility for an immigration request and to other entities and persons where necessary for the
administration and enforcement of U.S. immigration law.
4.

Applicant's Signature

Form I-192 Edition 07/20/21

Date of Signature (mm/dd/yyyy)

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Part 4. Interpreter's Contact Information, Certification, and Signature
Interpreter's Full Name
1.

Interpreter's Family Name (Last Name)

2.

Interpreter's Business or Organization Name

Interpreter's Given Name (First Name)

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Interpreter's Contact Information
3.

Interpreter's Daytime Telephone Number

5.

Interpreter's Email Address (if any)

4.

Interpreter's Mobile Telephone Number (if any)

Interpreter's Certification

I certify, under penalty of perjury, that I am fluent in English and
and I have interpreted every question on the application and instructions and interpreted the applicant's answers to the questions in
that language, and the applicant informed me that they understood every instruction, question, and answer on the application.
6.

Interpreter's Signature

,

Date of Signature (mm/dd/yyyy)

Part 5. Contact Information, Declaration, and Signature of the Person Preparing this Application,
if Other Than the Applicant
Preparer's Full Name
1.

Preparer's Family Name (Last Name)

2.

Preparer's Business or Organization Name

Preparer's Given Name (First Name)

Preparer's Contact Information
3.

Preparer's Daytime Telephone Number

5.

Preparer's Email Address (if any)

4.

Preparer's Mobile Telephone Number (if any)

Preparer's Certification
I certify, under penalty of perjury, that I prepared this application for the applicant at their request and with express consent and that
all of the responses and information contained in and submitted with the application is complete, true, and correct and reflects only
information provided by the applicant. The applicant reviewed the responses and information and informed me that they understand
the responses and information in or submitted with the application.
6.

Preparer's Signature

Form I-192 Edition 07/20/21

Date of Signature (mm/dd/yyyy)

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Part 6. 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.

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1.

Family Name (Last Name)

2.

A-Number (if any) ► A-

3.

Page Number

Part Number

Item Number

4.

Page Number

Part Number

Item Number

5.

Page Number

Part Number

Item Number

6.

Page Number

Part Number

Item Number

7.

Page Number

Part Number

Item Number

Form I-192 Edition 07/20/21

Given Name (First Name)

Middle Name (if applicable)

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