Birth Date, Day

Choose the day on which you were born. The day of birth is required to complete the application or to check the status of your application.

Birth Date, Month

Choose the month in which you were born. The month of birth is required to complete the application or to check the status of your application.

Birth Date, Year

Choose the year in which you were born. The year of birth is required to complete the application or to check the status of your application.

Country of Citizenship

Choose the country of citizenship, as it appears on your passport. The country of citizenship is required to complete the application.

Country Where You Live

Choose the country in which you reside. The country where you live is required to complete the application.

E-mail Address

Enter the e-mail address at which you can be contacted. The e-mail address is optional to complete the application.

Family Name

Enter your family name as the family name appears on your passport under the Family Name or Surname field. The family name is required to complete the application.

First (Given) Name

Enter your first (given) name as the first name appears on your passport under the First or Given Name field. Do not include the middle name in this field. First name is required to complete the application. If you do not have a first name, then enter the letters FNU which stands for First Name Unknown.

Sex

Choose your gender, either male or female. The sex (gender) is required to complete the application.

Telephone Number, Country Code

Choose the country code of the telephone number where you can be contacted. The country code and telephone number are optional to complete the application.

Telephone Number

Enter the telephone number where you can be contacted. The telephone number is optional to complete the application.

Passport Expiration Date, Day

Choose the day on which your passport expires, as it appears on your passport under the Expiration Date or Extension field. The day on which the passport expires is required to complete the application.

Passport Expiration Date, Month

Choose the month in which your passport expires, as it appears on your passport under the Expiration Date or Extension field. The month in which the passport expires is required to complete the application.

Passport Expiration Date, Year

Choose the year in which your passport expires, as it appears on your passport under the Expiration Date or Extension field. The year in which the passport expires is required to complete the application.

Passport Issuance Date, Day

Choose the day on which your passport was issued, as it appears on your passport under the Date of Issue field. The day on which the passport was issued is required to complete the application.

Passport Issuance Date, Month

Choose the month in which your passport was issued, as it appears on your passport under the Date of Issue field. The month in which the passport was issued is required to complete the application.

Passport Issuance Date, Year

Choose the year in which your passport was issued, as it appears on your passport under the Date of Issue field. The year in which the passport was issued is required to complete the application.

Passport Issuing Country

Choose the country that issued your passport. The passport issuing country is required to complete the application.

Passport Number

Enter your passport number as it appears on your passport. The passport number is required to complete the application or to check the status of your application.

Airline, Carrier Code

Choose the carrier code for the airline on which you will be traveling to the United States, if your travel information is available. The carrier code is a two-character code assigned to each airline. The carrier code is optional to complete the application.

Airline, Flight Number

Enter the flight number for the airline on which you will be traveling to the United States, if your travel information is available. The flight number is optional to complete the application.

City Where You are Boarding

Enter the last city where you will board an aircraft prior to arriving in the United States on this trip. The city where the applicant will board is optional to complete the application.

Address Line 1

Enter the number and street of the location where you will stay while in the United States. Do not include the city and state in this field. Address Line 1 is optional to complete the application.

• If multiple locations are planned, enter the first address.

• If the complete address is not known, enter the name of the hotel or location you will visit. You may update this information once confirmed.

• If you are leaving the United States immediately and do not have an address, enter the words ”In Transit” and your final destination location.

Address Line 2

Enter apartment, suite, unit, floor, building, or other, if appropriate. Do not include the city and state in this field. Address line 2 is optional to complete the application.

City

Enter the city of the address where you will stay while in the United States. The city is optional to complete the application.

State

Enter the state of the address where you will stay while in the United States. The state is optional to complete the application.

A) Do you have a communicable disease; physical or mental disorder; or are you a drug abuser or addict?

Communicable Diseases

Under United States law communicable diseases of public health significance include:

• Chancroid

• Gonorrhea

• Granuloma inguinale

• Human immunodeficiency virus (HIV) infection

• Leprosy, infectious

• Lymphogranuloma venereum

• Syphilis, infectious stage

• Tuberculosis, active

• And others as determined by the Department of Health and Human Services.    

Physical or Mental Disorders

With regard to physical or mental disorders, answer ”Yes” to this question if:

(a) You currently have a physical or mental disorder and a history of behaviour associated with the disorder that may pose or has posed a threat to your property, safety or welfare or that of others; or

(b) You had a physical or mental disorder and a history of behaviour associated with the disorder that has posed a threat to your property, safety or welfare or that of others and the behaviour is likely to recur or lead to other harmful behaviour

Answer ”No” if:

(a) You currently have no physical or mental disorders; or

(b) You have or had a physical or mental disorder without associated behaviour that may pose or has posed a threat to your property, safety or welfare of that of others; or

(c) You currently have a physical or mental disorder with associated behaviour, but that behaviour has not posed, does not currently pose nor will pose a threat to your property, safety or welfare or that of others; or

(d) You had a physical or mental disorder with associated behaviour that posed a threat to your property, safety or welfare or that of others, but that behaviour is unlikely to recur.

Drug Abusers and Drug Addicts

Under United States law persons may not be admissible if they have been determined to be a drug abuser or drug addict.

For further information refer to § 212(a)(1)(A) of the Immigration and Nationality Act, 8 U.S.C. § 1182(a)(1)(A), and corresponding regulations in the Code of Federal Regulations.

B) Have you ever been arrested or convicted for an offense or crime involving moral turpitude or a violation related to a controlled substance; or been arrested or convicted for two or more offenses for which the aggregate sentence to confinement was five years or more; or been a controlled substance trafficker; or are you seeking entry to engage in criminal or immoral activities?

Crimes involving moral turpitude - Such offenses generally involve conduct which is inherently base, vile, or depraved and contrary to the accepted rules of morality and the duties owed to persons or society in general. There are factors, such as the age of the offender or the date of the offense, that may affect whether an offense will be considered a crime involving moral turpitude for purposes of the Immigration and Nationality Act.  

For further information refer to § 212(a)(2) of the Immigration and Nationality Act, 8 U.S.C. § 1182(a)(2), § 101(a)(43) of the Immigration and Nationality Act, 8 U.S.C. § 1101(a)(43) and corresponding regulations in the Code of Federal Regulations.

D) Are you seeking to work in the U.S.; or have you ever been excluded and deported; or been previously removed from the United States; or procured or attempted to procure a visa or entry into the U.S. by fraud or misrepresentation?

Individuals entering the United States under the Visa Waiver Program are admitted as non-immigrant alien visitors and may not seek employment in the United States. While Visa Waiver Program travelers may not seek employment in the United States, there are many classifications of non-immigrant and immigrant employment-sponsored visas for those who qualify.

For further information refer to § 212(a)(5) of the Immigration and Nationality Act, 8 U.S.C. § 1182(a)(5).  

For further information on non-immigrant and immigrant employment visas, refer to www.travel.state.gov.

E) Have you ever detained, retained, or withheld custody of a child from a U.S. citizen granted custody of the child?

Any alien who, after entry of an order by a court in the United States granting custody to a person of a United States citizen child who detains or retains the child, or withholds custody of the child, outside the United States from the person granted custody by that order, is inadmissible until the child is surrendered to the person granted custody by that order.

For further information refer to § 212(a)(10)(C) of the Immigration and Nationality Act, 8 U.S.C. § 1182(a)(10)(C).

G) Have you ever asserted immunity from prosecution?

With regard to immunity from prosecution, answer ”Yes” to this question if all of the following apply:

(a) you have committed a serious criminal offense in the United States as defined in 8 U.S.C. Sec. 1101(h), including any felony, at any time for which immunity from criminal jurisdiction was exercised; and

(b) as a consequence of the offense and exercise of immunity identified in (a), you have departed from the United States; and

(c) you have not subsequently submitted fully to the jurisdiction of the court in the United States having jurisdiction with respect to that offense.

For further information refer to § 212(a)(2)(E) and 101(h) of the Immigration and Nationality Act, 8 U.S.C. § 1182(a)(2)(E) and 1101(h).