i-94Form
SampleForm
Actual Formswillbedistributedinflight
The I-94WNonimmigrantVisaWaiverArrival/Departure formmust be
completedby every nonimmigrant visitor not inpossessionof a valid visa
who is anational of one of the following countries:
ANDORRA
AUSTRALIA
AUSTRIA
BELGIUM
BRUNEI
DENMARK
FINLAND
FRANCE
GERMANY
ICELAND
IRELAND
ITALY
JAPAN
LIECHTENSTEIN
LUXEMBOURG
MONACO
NETHERLANDS
NEWZEALAND
NORWAY
PORTUGAL
SANMARINO
SINGAPORE
SLOVENIA
SPAIN
SWEDEN
SWITZERLAND
UNITEDKINGDOM
i-94wVisawaiverForm
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Português
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Español
Welcome to theUnitedStates
I-94WNonimmigrantVisaWaiverArrival/DepartureForm
Instructions
This form is to be completed by every nonimmigrant visitor not in possession of a
visitor's visa, who is a national of one of the countries enumerated in 8 CFR 217.
The airline canprovideyourwith the current listof eligible countries.
AdmissionNumber
ArrivalRecord
1.FamilyName
2.First (Given)Name
3.BirthDate
(day/mo/yr)
5.Sex
(maleor female)
4.CountryofCitizenship
6.PassportNumber
7.Airline andFlightNumber
8.CountryWhereYouLive
9.CityWhereYouBoarded
10.AddressWhile in theUnitedStates
(Number andStreet)
StapleHere
SeeOtherSide
OMBNo. 1651-0113
DEPARTMENTOFHOMELANDSECURITY
U.S.Customs andBorderProtection
12.
CBPForm I-94W (10/04)
OMBNo. 1651-0113
CBPForm I-94W (10/04)
Typeorprint legiblywith pen inALLCAPITALLETTERS.
USEENGLISH
Thisformisintwoparts. PleasecompleteboththeArrivalRecord,items
1
through
11
and the Departure Record, items
14
through
17
. The reverse side of this form
must be signed and dated. Childrenunder the age of fourteenmust have theirform
signedby aparent/guardian.
Item7
-IfyouareenteringtheUnitedStatesbyland,enter
LAND
inthisspace.If
you are entering theUnitedStates by ship, enter
SEA
in this space.
VISAWAIVER
11.City andState
GovernmentUseOnly
13.
14.FamilyName
15.First (Given)Name
16.BirthDate
(day/mo/yr)
17.Country ofCitizenship
VISAWAIVER
DepartureNumber
DEPARTMENTOFHOMELANDSECURITY
U.S.Customs andBorderProtection
Port:
Date:
Carrier:
Flight# /ShipName:
Important
-
Retain thispermit inyourpossession;youmust surrender itwhen you leave theU.S.
Failure todo somaydelay your entry into theU.S. in the future.
You are authorized to stay in theU.S. only until the datewrittenon this form. To remain past thisdate,
without permission fromDepartmentofHomelandSecurity authorities, is a violation of the law.
Surrender this permitwhen you leave theU.S.:
-By sea or air, to the transportation line;
-Across theCanadianborder, to aCanadianOfficial;
-Across theMexicanborder, to aU.S.Official.
Warning:
You may not accept unauthorized employment; or attend school; or represent the
foreigninformationmediaduringyourvisitunderthisprogram. YouareauthorizedtostayintheU.S.
for 90 days or less. You may not apply for: 1) a change of nonimmigrant status; 2) adjustment of
status to temporary or permanent resident, unless eligible under section 201(b) of the INA; or 3) an
extensionofstay. Violationofthesetermswillsubjectyoutodeportation. Anypreviousviolationof
this program, including having previously overstayed on this program without proper DHS
authorization,willresultinafindingofinadmissibilityasoutlinedinSection217oftheImmigration
andNationalityAct.
Do any of the following apply to you?
(Answer Yes orNo)
DepartureRecord
A.Do you have a communicable disease; physical ormental
disorder; or are you a drug abuser or addict?
B.Have you ever been arrested or convicted for an offense or crime
involvingmoral turpitudeor a violation related to a controlled
substance; or been arrested or convicted for two ormore offenses
forwhich the aggregate sentence to confinementwas five years
ormore; or been a controlled substance trafficker; or areyou
seeking entry to engage in criminal or immoral activities?
Yes No
Yes No
C.Have you ever been or are you now involved in espionageor
sabotage; or in terrorist activities; or genocide; or between 1933
and 1945were involved, in anyway, in persecutions associated
withNaziGermany or its allies?
Yes No
D.Are you seeking towork in theU.S.;or have everbeen excluded
and deported; or beenpreviously removed from theUnited
States; or procuredor attempted to procure a visa or entry into the
U.S. by fraud ormisrepresentation?
Yes No
E.Have you ever detained, retainedorwithheld custody of a
child from aU.S. citizen granted custody of the child?
F.Have you ever been denied aU.S. visa or entry into theU.S. or
had aU.S. visa cancelled? If yes,
Yes No
Yes No
when?
where?
G.Have you ever asserted immunity from prosecution?
Yes No
IMPORTANT:
If you answered
"Yes"
to any of the above, please
contact theAmericanEmbassy
BEFORE
you travel to theU.S. since
youmay be refused admission into theUnitedStates.
FamilyName
(PleasePrint)
CountryofCitizenship
FirstName
DateofBirth
WAIVER OF RIGHTS:
I hereby waive any rights to review or appeal of a U.S.
Customs and Border Protection officer's determination as to my admissibility, or to
contest, other thanon the basis of an application for asylum, any action in deportation.
CERTIFICATION:
I certify that I have read and understand all the questions and
statements on this form. The answers I have furnished are true and correct to the best of
myknowledge and belief.
Signature
Date
PublicReportingBurden -
Theburdenforthiscollectioniscomputedasfollows:
(1) Learning about the form 2 minutes; (2) completing the form 4 minutes for an
estimatedaverageof6minutesperresponse. Commentsconcerningtheaccuracyof
this burden estimate and suggestions for reducing this burden should be directed to
U.S.CustomsandBorderProtection,InformationServicesBranch,Washington,DC
20229 and the Office of Management and Budget, Paperwork Reduction Project,
OMBNo. (1651-0113),Washington,DC20503.
s
.
e
DEPARTMENTOFHOMELANDSECURITY
U.S.Customs andBorderProtection
O formulário I-94, Registrode
Chegada/Saída, deveserpreen-
chidopor todasaspessoas,
excetocidadãosamericanos,
estrangeiros residentesnos
EstadosUnidos, estrangeiros
comvistosde imigrantee
cidadãos canadenses emvisita
ouem trânsito. Este formulário
registraachegadae saídade
visitantesaosEstadosUnidos.
Escrevaapenasnaparteda
frente, em inglês eem letras
maiúsculas. Guardeeste
formulárioatéa sua saídados
EstadosUnidos. Agradecemos
a suacolaboração.
1. Sobrenome
2. Nome
3. Datadenascimento
(dia/mês/ano)
4. Paísdecidadania
5. Sexo (masculinoou
feminino)
6. Númerodopassaporte
7. Companhiaaéreae
númerodovôo
8. Paísde residência
9. Cidadedeembarque
10. Cidadedaemissão
dovisto
11. Datadaemissão
(dia/mês/ano)
12. Endereçoenquanto
estiver nosEstados
Unidos (Númeroe rua)
13. CidadeeEstado
14. Sobrenome
15. Nome
16. Datadenascimento
(dia/mês/ano)
17. Paísdecidadania
Tous les ressortissants
étrangers, à l’exceptiondes
ressortissants américains,
des résidentspermanentsde
retour auxEtats-Unis, des
étrangers enpossessionde
visad’immigration, ainsi que
des ressortissants canadiens
envisiteouen transit, doi-
vent compléter le formulaire
d’Arrivéeet deDépart I-94.
Ce formulaireenregistre
l’arrivéeet ledépart des
visiteurs auxEtats-Unis.
Veuillez remplir seulement la
premièrepagedu formulaire
enanglais et enmajuscules.
Veuillezgarder ce formulaire
jusqu’àvotredépart des
Etats-Unis. Nous vous remer-
cionsdevotre collaboration.
1. Nomde famille
2. Prénom
3. Datedenaissance
(jour/mois/an)
4. Paysdenationalité
5. Sexe (masculinou
féminin)
6. Numérodepasseport
7. Ligneaérienneet
numérodevol
8. Paysde résidence
9. Villeoùvous avez
embarqué
10. Villeoù levisaaété
délivré
11. D tededélivrance
(jour/mois/an)
12. Adresse lorsdevotre
séjour auxEtats-Unis
(Numéroet rue)
13. Villeet état
14. Nomde famille
15. Prénom
16. Datedenaissance
(jour/mois/an)
17. Paysdenationalité
El formulario I-94, Registrode
Llegada/Salida, debe ser llena-
dopor todapersona (excepto
ciudadanosde losEstados
Unidos, extranjeros residentes
enEstadosUnidosqueestán re-
gresando, extranjeros convisa
de inmigrante, y ciudadanos
deCanadádevisitaode trán-
sito). Este formulario
registra la llegaday salida
devisitantes a losEstados
Unidos. Escribaenel anverso
solamente, con letramayús-
culayen inglés. Guardeeste
formulariohast que salgade
losEstadosUnidos, ygracias
por su cooperación.
1. Apellidopaterno
2. Primer nombre
3. Fechadenacimiento
(día/mes/año)
4. Paísde ciudadanía
5. Sexo (masculinoo
femenino)
6. Númerodepasaporte
7. Líneaaéreaynúmero
devuelo
8. PaísdondeUd. vive
9. Ciudaddondeabordó
el avión
10. Ciudaddonde seemitió
suvisa
11. Fechaemitida (día/
mes/año)
12. Sudirecciónmientras
estéen losEstados
Unidos (Númeroy calle)
13. CiudadyEstado
14. Apellidopaterno
15. Primer nombre
16. Fechadenacimiento
(día/mes/año)
17. Paísde ciudadanía
2.
3.
4.
5.
9.
10.
11.
12.
13.
14.
15.
16.
17.
6.
7.
8.
1.
Welcome to theUnitedStates
I-94WNonimmigrantVisaWaiverArrival/DepartureForm
Instructions
Thisformistobecompletedbyeverynonimmigrantvisitornotinpossessionofa
visitor'svisa,whoisanationalofoneofthecountriesenumeratedin8CFR217.
The airline can provideyourwith the current listof eligible countries.
AdmissionNumber
ArrivalRecord
1.FamilyName
2.First (Given)Name
3.BirthDate
(day/mo/yr)
5.Sex
(maleor female)
4.Country ofCitizenship
6.PassportNumber
7.Airline andFlightNumber
8.CountyWhereYouLive
9.CiyWereYouBoarded
10.AddressWhile in theUnitedStates
(Numberand Street)
StapleHere
SeeOtherSide
OMBNo. 1651-0113
DEPARTMENTOFHOMELANDSECURITY
U.S.Customs andBorderProtection
12.
CBPForm I-94W (10/04)
OMBNo. 1651-0113
CBPForm I-94W (10/04)
Typeor print legiblywithpen inALLCAPITALLETTERS.
USEENGLISH
Thisformisintwoparts. PleasecompleteboththeArrivalRecord,items
1
through
11
andtheDepartureRecord,items
14
through
17
. Thereversesideofthisform
mustbesignedanddated. Childrenundertheage fourteenmusthvetheirf m
signedby a parent/guardian.
Item7
-IfyouareenteringtheUnitedStatesbyland,enter
LAND
inthisspace.If
you are entering theUnitedStates by ship, enter
SEA
in this space.
VISAWAIVER
11.City andState
Government se nly
13.
14.FamilyName
15.First (Given)Name
16.BirthDate
(day/mo/yr)
17.CountryofCitizenship
VISAWAIVER
DepartureNumber
DEPARTMENTOFHOMELANDSECURITY
U.S.CustomsandBorderProtection
Port:
Date:
Carrier:
Flight# /ShipName:
Important
-
Retain this permit in yourpossession; youmust surrender itwhen you leave theU.S.
Failure todo somay delay your entry into theU.S. in the future.
You are authorized to stay in theU.S.only until the datewritten on this form. To remain past this date,
without permission fromDepartmentofHomelandSecurity authorities, is aviolation of the law.
Surrender thispermitwhen you leave theU.S.:
-By seaor air, to the transportation line;
-Across theCanadianborder, to aCanadianOfficial;
-Across theMexican border, to aU.S.Official.
Warning:
Youmaynotacceptunauthorizedemployment;orattendschool;orrepresentthe
foreigninformationmediaduringyourvisitunderthisprogram. YouareauthorizedtostayintheU.S.
for90daysorless. Youmaynotapplyfor:1)achangeofnonimmigrantstatus;2)adjustmentof
statustotemporaryorpermanentresident,unlesseligibleundersection201(b)oftheINA;or3)an
extensionofstay. Violationofthesetermswillsubjectyoutodeportation. Anypreviousviolationof
this program, including having previously overstayed on this program without proper DHS
authorization,willresultinafindingofinadmissibilityasoutlinedinSection217oftheImmigration
andNationalityAct.
Doanyof the following apply toyou?
(AnswerYes orNo)
DepartureRecord
A.Do youhave a communicabledisease;physicalormental
disorder;or areyou a drug abuseror addict?
B.Haveyou ever been arrested or convicted for an offenseor crime
involvingmoral turpitude or a violation related to a controlled
substance;orbeen arrestedor convicted for twoormoreoffenses
forwhich the aggregate sentence to confinementwas five years
ormore; or been a controlled substance trafficker; or are you
seeking entry to engage in criminalor immoral activities?
Yes No
Yes No
C.Haveyou ever beenor areyounow involved in espionage or
sabotage; or in terrorist activities; or genocide; orbetween 1933
and1945were involved, in anyway, in persecutions associated
withNaziGermany or its allies?
Yes No
D.Are you seeking towork in theU.S.;or have everbeen excluded
anddeported; orbeenpreviously removed from theUnited
States;orprocuredor attempted toprocure avisaor entry into the
U.S.by fraud ormisrpresentation?
Yes No
E.Have you ever detained, retainedorwithheld custody of a
child from aU.S. citizen granted custodyof the child?
F.Haveyou everbeen denied aU.S.visa or entry into theU.S.or
had aU.S.visa cancelled? Ifyes,
Yes No
Yes No
when?
where?
G.Have you ever asserted immunity from prosecution?
Yes No
IMPORTANT:
Ifyou answered
"Yes"
to any of the above, please
contact theAmericanEmbassy
BEFORE
you travel to theU.S. since
youmay be rfused admission into theUnitedStates.
FamilyName
( leasePrint)
Country ofCitizenship
FirstName
DateofBirth
WAIVER OF RIGHTS:
IherebywaiveanyrightstorevieworappealofaU.S.
Customs and Border Protection officer's determination as to my admissibility, or to
contest, other than on the basis of an application for asylum, any action in deportation.
CERTIFICATION:
IcertifythatIhavereadandunderstandallthequestionsand
stateme tsont isform. TheanswersIhavefurnishedaretrueandcorrecttothebestof
my knowledge andbelief.
Signature
Date
PublicReportingBurden-
Theburdenforthiscollectioniscomputedasfollows:
(1)Learningabouttheform2minutes;(2)completingtheform4minutesforan
estimatedaverageof6minutesperresponse. Commentsconcerningtheaccuracyof
thisb rdenestimateandsuggestionsforreducingthisburdenshouldbedirectedto
U.S.CustomsandBorderProtection,InformationServicesBranch,Washington,DC
20229andtheOfficeofManagementandBudget,PaperworkReductionProject,
OMBNo. (1651-0113),Washington,DC 20503.
s
.
e
DEPARTMENTOFHOMELANDSECURITY
U.S.Customs andBorderProtection
DECEMBER 1 2008
AMERiCANwAY 105
