What is your name as written on your passport?
Please separate given name(s) and surname(s) by a line.
Example: James Henry | Adams Blake
First Name
Last Name
Are you known by any other names or aliases?
Yes
No
If so, what?
Day
*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
*
January
February
March
April
May
June
July
August
September
October
November
December
Year
*
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
City of birth:
Country of birth:
Gender:
Female
Male
Are you a member of the CBP Global Entry Program?
Yes
No
Mother's full name:
First Name
Last Name
Father's full name:
First Name
Last Name
What is your current foreign address?
This is an address outside of the United States.
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email:
Confirm email:
Telephone number with country code:
Please include the full number with the country code.
Country
(###)
###
####
Passport number:
Passport issuing country:
Passport date issued:
MM
DD
YYYY
Passport expiration date:
MM
DD
YYYY
Country of citizenship:
Have you ever been issued a passport or national identity card for travel by any other country?
Yes
No
Are you now a citizen or national of any other country?
Yes
No
Have you ever been a citizen or national of any other country?
Yes
No
Name of your emergency contact:
This can be a person in or outside of the United States.
First Name
Last Name
Telephone number of emergency contact:
Email address of emergency contact:
Is your travel to the U.S. occurring in transit to another country?
Yes
No
Please list all social media usernames and passwords:
Do you have a current or previous employer?
Yes
No
If yes, please answer the below questions regarding your most recent/current job.
Please enter all of this information.
1. Job title
2. Employer name
3. Full address
4. Phone number with country code
Have you ever been arrested or convicted for a crime that resulted in serious damage to property, or serious harm to another person or government authority?
Yes
No
Have you ever violated any law related to possessing, using, or distributing illegal drugs?
Yes
No
Do you seek to engage in or have you ever engaged in terrorist activities, espionage, sabotage, or genocide?
Yes
No
Have you ever committed fraud or misrepresented yourself or others to obtain, or assist others to obtain, a visa or entry into the United States?
Yes
No
Are you currently seeking employment in the United States or were you previously employed in the United States without prior permission from the U.S. government?
Yes
No
Have you ever been denied a U.S. visa you applied for with your current or 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?
Yes
No
Have you ever stayed in the United States longer than the admission period granted to you by the U.S. government?
Yes
No
Have you traveled to, or been present in Iran, Iraq, Libya, North Korea, Somalia, Sudan, Syria or Yemen on or after March 1, 2011?
Yes
No
Name of U.S. contact:
First Name
Last Name
Phone of U.S. contact:
Address of U.S. contact:
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
