Family Name*

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First (Given) Name*

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Click if you are known by any other names or aliases

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Date of Birth*

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City of Birth*

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Country of Birth*

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Parent 1 Family Name*

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Parent 1 First (Given) Name*

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Parent 2 Family Name*

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Parent 2 First (Given) Name*

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Passport Number*

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Passport Issuing Country

Passport Issuance Date*

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Passport Expiration Date*

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Country of Citizenship*

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Click if you are a citizen of any other country

Other citizenships. Country 1

Other citizenships. Country 1. Passport Number.

Other citizenships. Country 1. How did you acquire citizenship

Other citizenships. Country 2

Other citizenships. Country 2. Passport Number.

Other citizenships. Country 2. How did you acquire citizenship

Click if you have ever been a citizen of any other country

Former citizenships. Country 1

Former citizenships. Country 2

Click if you have ever been issued a Passport or National Identity Card for travel by any other country

Former citizenships doc. Issuing Country 1

Former citizenships doc. Doc Type (P = Passport; I = Identity Card) 1

Former citizenships doc. Doc Number 1

Former citizenships doc. Expiration Year 1

Former citizenships doc. Issuing Country 2

Former citizenships doc. Doc Type (P = Passport; I = Identity Card) 2

Former citizenships doc. Doc Number 2

Former citizenships doc. Expiration Year 2

Click if you are a member of the CBP Global Entry Program

State your PASSID / Membership Number

e-Mail Address 1

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e-Mail Address 2

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e-Mail Address 3

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Home telephone number (including country code)*

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Mobile telephone number (including country code)*

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Work telephone number (including country code)*

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Home address. Address*

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Home address. City*

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Home address. State/Province/Region*

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Home address. Country*

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Emergency Contact. Family Name

Emergency Contact. First (Given) Name

Emergency Contact. Telephone Number (including country code)

Emergency Contact. e-Mail Address

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Click if your travel to the US is occurring in transit to another country

Address while in the US. Full address

Address while in the US. City

Address while in the US. State

US Point of Contact

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US Point of Contact. City

US Point of Contact. State

US Point of Contact. Telephone number

Click if you have a current or previous employer

Employer Name

Job Title

Employer. Full address

Employer. Country

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Provider / Platform 1:

Social media Identifier 1:

Provider / Platform 2:

Social media Identifier 2:

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Click if you have viral hemorrhagic fevers, including ebola, lassa, marburg, Crimean-congo

Click if you have severe acute respiratory illnesses capable of transmission to Other persons and likely to cause mortality.

Click if you have ever been arrested or convicted for a crime that resulted in serious damage to property, or serious harm to another person or government authority

Click if you have ever violated any law related to possessing, using, or distributing illegal drugs

Click if you seek to engage in or have you ever engaged in terrorist activities, espionage, sabotage, or genocide

Click if you have ever committed fraud or misrepresented yourself or others to obtain, or assist others to obtain, a visa or entry into the United States

Click if you are currently seeking employment in the United States or were you previously employed in the United States without prior permission from the U.S. government?

Click if you have ever been denied a U.S. visa you applied for with your current or previous passport

U.S. visa denied. When

U.S. visa denied. Where

Click if you have ever been refused admission to the U.S. or withdrawn your application for admission at a U.S. port of entry

Refused admission to the U.S. When

Refused admission to the U.S. Where

Click if you have ever stayed in the U.S. longer than the admission period granted to you by the U.S. government

Click if you have traveled to, or been present in Iraq, Syria, Iran, Sudan, Libya, Somalia or Yemen on or after March 1, 2011

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U.S. ESTA requirement form