june-2010

I-94 NONIMMIGRANT VISA WAIVER / FRONT
DEPARTMENT OF HOMELAND SECURITY
OMB No. 1651-0111
U.S. Customs and Border Protection
Welcome to the United States
I-94W Nonimmigrant Visa Waiver Arrival/Departure Record
Instructions
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 15) and
the Departure Record (Items 18 through 21). 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.
Item 9 - If you are entering the United States by land, enter LAND in this space.
If you are entering the United States by ship, enter SEA in this space.
5 U.S.C. § 552a(e)(3) Privacy Act Notice: Information collected on this form 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 to other government agencies for law enforcement purposes
or to assist DHS in determining your admissibility. All nonimmigrant aliens seeking admission to the U.S., unless
otherwise exempted, must provide this information. Failure to provide this information may deny you entry to the
United States and result in your removal.
Admission Number
00000000000
Arrival Record
VISA WAIVER
1. Family Name
2. First (Given) Name 3. Birth Date (DD/MM/YY)
4. Country of Citizenship 5. Sex (Male or Female)
6. Passport Issue Date (DD/MM/YY) 7. Passport Expiration Date (DD/MM/YY)
8. Passport Number 9. Airline and Flight Number
10. Country Where You Live 11. City Where You Boarded
12. Address While in the United States (Number and Street)
13. City and State
14. Telephone Number in the U.S. Where You Can be Reached
15. Email Address
16. 17.
Admission Number
00000000000
Departure Record
VISA WAIVER
18. Family Name
See Other Side
CBP Form I-94W (05/08)
OMB No. 1651-0111
19. First (Given) Name 20. Birth Date (DD/MM/YY)
21. Country of Citizenship
Government Use Only
CBP Form I-94W (05/08)
STAPLE HERE
ENGLISH
Prior to arrival in the United States, foreign
nationals (except Canadian citizens and
U.S. permanent residents) who are not
in possession of a visitors visa and are
entitled to the Visa Waiver Program are
required to complete the I-94W form. One
form is required for each family member.
Customers should complete all personal
and travel-related information included
on the front side of the card. Please ensure
that you answer all questions and sign and
date where indicated on the back side of this
form. All customers must provide a U.S.
address for entry.
Countries that are participants of
the Visa Waiver Program are as follows:
Andorra, Australia, Austria, Belgium,
Brunei, *Czech Republic, Denmark,
*Estonia, Finland, France, Germany,
*Greece, *Hungary, Iceland, Ireland,
Italy, Japan, *Latvia, Liechtenstein,
STAYING FIT: INFLIGHT FLEXIBILITY
Knee Flexion: Lift knee toward
chest, decreasing the amount of
joint space at back of the knee.
Repeat with other leg.
Knee Extension: Straighten knee,
increasing the amount of joint
space at the back of the knee
to its full range. Repeat with
other leg.
*Lithuania, Luxembourg, *Malta, Monaco,
the Netherlands, New Zealand, Norway,
Portugal, San Marino, Singapore, *Slovakia,
Slovenia, *South Korea, Spain, Sweden,
Switzerland, the United Kingdom.
*Nationals of these countries must present
an electronic (e-ppt) passport to be eligible
for the U.S. Visa Waiver Program.
Nationals of all Visa Waiver countries
must present a machine-readable passport
for the U.S. Visa Waiver Program.
SPANISH / ESPAÑOL
Antes de su llegada en los Estados Unidos,
los ciudadanos extranjeros (excepto
ciudadanos Canadienses y residentes
permanentes de los Estados Unidos) que
no tengan un visado de visita y se acojan
al programa “Visa Waiver”, tienen que
completar el formulario I-94W. Se requiere
un formulario por cado miembro de
familia. Los pasajeros deberán rellenar toda
información tanto personal como relacionada
con viajes en el anverso de la tarjeta. Por
favor, asegúrese de contestar todas las
preguntas , fi rmen y pongan la fecha en el
lugar indicado en el formulario. Todos los
pasajeros deben proporcionar una dirección
en Estados Unidos para entrar al país.
Los países que participan del Programa
de exención de visas son los siguientes:
Alemania. Andorra, Australia, Austria,
Bélgica, Brunei, *Corea del Sur, Dinamarca,
*Eslovaquia, Eslovenia, Espána, *Estonia,
Finlandia, Francia, *Grecia, *Hungría,
Irlanda, Islandia, Italia, Japón, *Letonia,
Liechtenstein, * Lituania, Luxemburgo,
*Malta, Mónaco, Noruega, Nueva Zelandia,
Países Bajos, Portugal,*República Checa,
San Marino, Singapur, Suecia, Suiza y el
Reino Unido.
*Los ciudadanos de estos países deben
presentar un electrónicos (e-ppt) pasaporte
para ser elegible para del Programa de
exención de visas de Estados Unidos.
Los ciudadanos de los demás países
exentos de visas deben presentar un
pasaporte de lectura electrónica en el marco
del Programa de exención de visas de
Estados Unidos a partir del 26 de octubre
de 2004.
1. Apellido
2. Nombre
3. Fecha de nacimiento
(Día/Mes/Año)
Do any of the following apply to you? (Answer Yes or No)
A. Do you have a communicable disease; physical or mental disorder, or are
Yes No
you a drug abuser or addict?
B. Have you ever been arrested or convicted for an offense or crime involving
Yes No
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?
C. Have you ever been or are you now involved in espionage or sabotage; or in
Yes No
terrorist activities; or genocide; or between 1933 and 1945 were involved, in
any way, in persecutions associated with Nazi Germany or its allies?
D. Are you seeking to work in the U.S.; or have ever been excluded and
Yes No
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?
E. Have you ever detained, retained or withheld custody of a child from a U.S.
Yes No
citizen granted custody of the child?
F. Have you ever been denied a U.S. visa or entry into the U.S. or had a U.S.
Yes No
visa cancelled? If yes,
when? ______________________ where? _________________________
G. Have you ever asserted immunity from prosecution?
Yes No
IMPORTANT: If you answered “Yes” to any of the above, please contact the American Embassy
BEFORE you travel to the U.S. since you may be refused admission into the United States.
Family Name (Please print) First Name
Country of Citizenship Date of Birth
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 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 my knowledge and belief.
Signature Date
Paperwork Reduction Act Statement: An agency may not conduct or 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 control number for this collection is 1651-0111. The estimated average
time to complete this application is 8 minutes per respondent. If you have any comments regarding the
burden estimate you can write to U.S. Customs and Border Protection, Asset Management, 1300
Pennsylvania Avenue, NW, 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 a proper DHS authorization, will
result in a finding of inadmissibility as outlined in Section 217 of the Immigration and Nationality Act.
Port:
Date:
Carrier:
Flight No./Ship Name:
4. Nacionalidad
5. Sexo (varón/hembra)
6. Fecha de emisión del pasaporte
7. Fecha de vencimiento del pasaporte
8. Número de pasaporte
9. Aerolínea y número de vuelo
10. País de residencia
11. País en el que abordó
12. Direccion donde se quedará en los
EE.UU (Número, calle)
13. Ciudad y Estado
14. Teléfono de contacto en EE.UU.
15. Dirección de correo electrónico
SPANISH / ESPAÑOL
¿Le afecta alguna de estas restricciones a
usted? (Conteste Si o No)
A. ¿Padece usted de alguna enfermedad
contagiosa, defi ciencia física o
mental, o es adicto a las drogas?
Sí / No
Dorsifl exion: With heel on fl oor, point
toes upward, decreasing the angle
between the foot and front of the leg.
Repeat with other foot.
Plantar Flexion: Lift the heel and
keep toes pointed toward the fl oor,
increasing the angle between the top
of the foot and front of the leg. Repeat
with other foot.
HEMISPHERESMAGAZINE.COM | JUNE 2010
I-94 NONIMMIGRANT VISA WAIVER / BACK
131
B. ¿Ha sido usted arrestado o condenado
por alguna infracción o delito de
depravación moral; o por una violación
relacionada con estupefacientes;
arrestado o condenado por dos o más
infracciones cuya sentencia total de
reclusión fuera igual o superior a cinco
años; ha sido trafi cante de estupefacientes,
o pretende entrar en los Estados Unidos
para realizar actividades criminales o
inmorales? Sí / No
C. ¿Ha estado o está implicado en actos
de espionaje o sabotaje, actividades
terroristas o genocidios; o participó
de algún modo entre 1933 y 1945
en persecuciones relacionadas con la
Alemania nazi o sus aliados? Sí / No
D. ¿Tiene intención de trabajar en los
Estados Unidos; ha sido excluido o
deportado; o ha sido expulsado de los
Estados Unidos, o ha obtenido
o intentado obtener un visado o la
entrada a los Estados Unidos por
medios fraudulentos o dando
información falsa? Sí / No
E. ¿Ha detenido, retenido, o impedido
la custodia de un niño que corresponda
legalmente a un ciudadano de los
Estados Unidos? Sí / No
F. ¿Se le ha cancelado o denegado
alguna vez el visado o la entrada en los
Estados Unidos? En caso afi rmitavo,
especifi que? Sí / No
¿Cúando? ¿Dónde?
G. ¿Ha hecho valer alguna vez su
inmunidad frente a un
procesamiento? Sí / No
IMPORTANTE: Si ha contestado
afi rmativamente alguna de las preguntas,
comuníquese con la Embajada de los Estados
Unidos ANTES de su viaje, ya que se le puede
denegar la entrada en los Estados Unidos.
RENUNCIA DE DERECHOS: Por la presente
renuncio el derecho a solicitar la revisión del
Ofi cial de Inmigración acerca de mi admisión
en los Estados Unidos, o a apelarla, o a
impugnar cualquier acto de deportación que
no sea por razón de una solicitud de asilo.
DECLARACIÓN: Declaro que he leído y
entendido todas las preguntas y enunciados
enumerados en esta solicitud, y que las
respuestas que he propocionado en este
formulario son verdaderas y
correctas a mi mejor saber y entender.
Eversion: With foot on fl oor,
gently roll the sole of the foot
inward. Repeat with other foot.
Inversion: With foot on fl oor,
gently roll the sole of the foot
outward. Repeat with other foot.