Sample CBP Form I-94W "Nonimmigrant Visa Waiver Arrival/Departure Record"

What Is CBP Form I-94W?

This is a legal form that was released by the U.S. Department of Homeland Security - Customs and Border Protection on December 1, 2016 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2016;
  • The latest available edition released by the U.S. Department of Homeland Security - Customs and Border Protection;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of CBP Form I-94W by clicking the link below or browse more documents and templates provided by the U.S. Department of Homeland Security - Customs and Border Protection.

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Download Sample CBP Form I-94W "Nonimmigrant Visa Waiver Arrival/Departure Record"

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Welcome to the United States
I-94W Nonimmigrant Visa Waiver Arrival/Departure Record
OMB NO. 1651-0111
CBP Form I-94W (12/16)
ARRIVAL RECORD Visa Waiver
Admission Number
This Space For Official Use Only
Instructions
0 0 0 0 FPO 0 0 0 0
This form must 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 can provide you with the
current list of eligible countries.
Type or print legibly with pen in ALL CAPITAL LETTERS. USE ENGLISH.
This form is in two parts. Please complete both the Arrival Record (Items 1 through 8) and the
Departure Record (Items 1 through 4). The reverse side of this form must be signed and dated.
Children under the age of fourteen must have their form signed by a parent or guardian.
1
4
Applicant Information
Contact Information
Applicant Name (Please print, ALL CAPS)
E-mail Address
Family Name
First (Given) Name
Telephone Number
Country Code/Number
Are you known by any other names or aliases?
Yes
No
Other Names/Aliases
Family Name
First (Given) Name
Home Address
Address Line 1
Apartment Number
Parents
Family Name
First (Given) Name
Address Line 2
City
State/Province/Region
Country
Birth Date (DD/MM/YY)
(Optional) Please enter information associated with your online presence.
Provider
Social Media Identifier
City of Birth
5
Emergency Contact Information
Country of Birth
Emergency Contact
Family Name
First (Given) Name
Gender (Male or Female)
Telephone Number
Country Code/Number
2
Passport Information
E-mail Address
Passport Number
Passport Issuing Country
6
Travel Information
Is your travel to the U.S. occurring in transit to another country?
Yes
No
Issuance Date (DD/MM/YY)
Expiration Date (DD/MM/YY)
Address while in the United States
Address Line 1
Apartment Number
Country of Citizenship
Address Line 2
City
National Identification Number
State
Are you a member of CBP Global Entry?
Yes
No
3
Citizenship Information
Please provide your Pass ID number.
Yes
No
Are you now a citizen or national of any other country?
If yes, what countries?
SEE OTHER SIDE
OMB NO. 1651-0111
How did you acquire citizenship?
Admission Number
This Space For Official Use Only
0 0 0 0 FPO 0 0 0 0
Have you ever been a citizen or national of any other country?
Yes
No
If yes, what countries?
Have you ever been issued a passport or national identity card for travel by any
Yes
No
other country?
DEPARTURE RECORD Visa Waiver
If yes, what is the document number?
Expiration Date
Family Name (Please print, ALL CAPS)
1
Additional document number
Expiration Date
First/Given Name
2
If you need more space to answer any of the questions please add it here.
Birth Date (DD/MM/YY)
3
Country of Citizenship
4
CBP Form I-94W (12/16)
STAPLE HERE
Welcome to the United States
I-94W Nonimmigrant Visa Waiver Arrival/Departure Record
OMB NO. 1651-0111
CBP Form I-94W (12/16)
ARRIVAL RECORD Visa Waiver
Admission Number
This Space For Official Use Only
Instructions
0 0 0 0 FPO 0 0 0 0
This form must 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 can provide you with the
current list of eligible countries.
Type or print legibly with pen in ALL CAPITAL LETTERS. USE ENGLISH.
This form is in two parts. Please complete both the Arrival Record (Items 1 through 8) and the
Departure Record (Items 1 through 4). The reverse side of this form must be signed and dated.
Children under the age of fourteen must have their form signed by a parent or guardian.
1
4
Applicant Information
Contact Information
Applicant Name (Please print, ALL CAPS)
E-mail Address
Family Name
First (Given) Name
Telephone Number
Country Code/Number
Are you known by any other names or aliases?
Yes
No
Other Names/Aliases
Family Name
First (Given) Name
Home Address
Address Line 1
Apartment Number
Parents
Family Name
First (Given) Name
Address Line 2
City
State/Province/Region
Country
Birth Date (DD/MM/YY)
(Optional) Please enter information associated with your online presence.
Provider
Social Media Identifier
City of Birth
5
Emergency Contact Information
Country of Birth
Emergency Contact
Family Name
First (Given) Name
Gender (Male or Female)
Telephone Number
Country Code/Number
2
Passport Information
E-mail Address
Passport Number
Passport Issuing Country
6
Travel Information
Is your travel to the U.S. occurring in transit to another country?
Yes
No
Issuance Date (DD/MM/YY)
Expiration Date (DD/MM/YY)
Address while in the United States
Address Line 1
Apartment Number
Country of Citizenship
Address Line 2
City
National Identification Number
State
Are you a member of CBP Global Entry?
Yes
No
3
Citizenship Information
Please provide your Pass ID number.
Yes
No
Are you now a citizen or national of any other country?
If yes, what countries?
SEE OTHER SIDE
OMB NO. 1651-0111
How did you acquire citizenship?
Admission Number
This Space For Official Use Only
0 0 0 0 FPO 0 0 0 0
Have you ever been a citizen or national of any other country?
Yes
No
If yes, what countries?
Have you ever been issued a passport or national identity card for travel by any
Yes
No
other country?
DEPARTURE RECORD Visa Waiver
If yes, what is the document number?
Expiration Date
Family Name (Please print, ALL CAPS)
1
Additional document number
Expiration Date
First/Given Name
2
If you need more space to answer any of the questions please add it here.
Birth Date (DD/MM/YY)
3
Country of Citizenship
4
CBP Form I-94W (12/16)
STAPLE HERE
Do any of the following apply to you? (Answer Yes or No)
7
U.S. Point of Contact Information
U.S. Point of Contact
Do you have a physical or mental disorder; or are you a drug abuser or addict;
1
Yes
No
or do you currently have any of the following diseases (communicable diseases
are specified pursuant to section 361(b) of the Public Health Service Act)?
Address
Cholera
Yellow Fever
Address Line 1
Apartment Number
Diphtheria
Viral Hemorrhagic Fevers, including Ebola,
Lassa, Marburg, Crimean-Congo
Address Line 2
City
Tuberculosis, infectious
Severe acute respiratory illnesses capable
Plague
of transmission to other persons and
State
Smallpox
likely to cause mortality.
Have you ever been arrested or convicted for a crime that resulted in serious
2
Yes
No
Telephone Number
damage to property, or serious harm to another person or government authority?
Country Code/Number
Have you ever violated any law related to possessing, using, or distributing
3
Yes
No
illegal drugs?
8
Employment Information
Do you seek to engage in or have you ever engaged in terrorist activities,
4
Yes
No
Do you have a current or previous employer?
espionage, sabotage, or genocide?
Yes
No
Employer Name
Have you ever committed fraud or misrepresented yourself or others to obtain
5
Yes
No
or assist others to obtain a visa or entry into the United States?
Address
Address Line 1
Apartment Number
Are you currently seeking employment in the United States or were you
6
Yes
No
previously employed in the United States without prior permission from the
Address Line 2
City
U.S. government?
Have you ever been denied a U.S. visa you applied for with your current or
7
Yes
No
State/Province/Region
Country
a previous passport or have you ever been refused admission to the United
States or withdrawn your application for admission at a U.S. port of entry? If yes,
when? _____________________ where? ___________________________________
Telephone Number
Country Code/Number
Have you ever stayed in the United States longer than the admission period
8
Yes
No
granted to you by the U.S. government?
Job Title
Have you traveled to, or been present in, Iran, Iraq, Libya, Somalia, Sudan,
9
Yes
No
Syria, or Yemen on or after March 1, 2011?
If yes was it for
Official government business
Military service on behalf of a Visa Waiver Program country
5 U.S.C. § 552a(e)(3) PRIVACY ACT NOTICE: Information collected on this form
If yes, when?
is required by Title 8 of the U.S. Code, including the INA (8 U.S.C. 1103, 1187),
and 8 CFR 235.1, 264, and 1235.1. The purposes for this collection are to give
the terms of admission and document the arrival and departure of nonimmigrant
aliens to the U.S. The information solicited on this form may be made available
IMPORTANT: If you answered “Yes” to any of the above, please contact the American Embassy
to other government agencies for law enforcement purposes or to assist DHS
BEFORE you travel to the U.S. since you may be refused admission into the United States.
in determining your admissibility. All nonimmigrant aliens seeking admission to
the U.S., unless otherwise exempted, must provide this information. Failure to
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 than on the basis of
provide this information may deny you entry to the United States and result in
an application for asylum, any action in deportation.
your removal.
CERTIFICATION: I certify that I have read and understand all the questions and statements on this
PAPERWORK REDUCTION ACT STATEMENT: An agency may not conduct or
form. The answers I have furnished are true and correct to the best of my knowledge and belief.
sponsor an information collection and a person is not required to respond to
this information unless it displays a current valid OMB control number. The
Signature
Date
control number for this collection is 1651-0111. The estimated average time to
complete this application is 16 minutes. If you have any comments regarding this
burden estimate you can write to U.S. Customs and Border Protection, Office of
Regulations and Rulings, 90 K Street, NE, 10th Floor, Washington, DC 20229.
Departure Record
IMPORTANT: Retain this permit in your possession; you must surrender it when you leave the U.S.
Failure to do so may delay your entry into the U.S. in the future.
You are authorized to stay in the U.S. only until the date written on this form. To remain past this
date without permission from Department of Homeland Security authorities, is a violation of the law.
Surrender this permit when you leave the U.S.:
• By sea or air, to the transportation line;
• Across the Canadian border, to a Canadian Official;
• Across the Mexican border, to a U.S. Official.
WARNING: You may not accept unauthorized employment; or attend school; or represent the foreign
information media during your visit under this program. You are authorized to stay in the U.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 extension
of stay. Violation of these terms will subject you to deportation. Any previous violation of this program,
including having previously overstayed on this program without proper DHS authorization, may result
in a finding of inadmissibility as outlined in Section 217 of the Immigration and Nationality Act.
Port
Date
Carrier
Flight No./Ship Name
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