Main Applicant Details
Are you known by any other names or aliases? *
Country of Birth *
In what country do you live? *
What country are you a citizen of? *
Which country issued your passport? *
Are you a citizen of any other country?*
Emergency Contact Information (In or outside United States)
Is your travel to the US occurring in transit to another country? *
Do you have a current or previous employer? *
Please confirm the responses to the following mandatory questions
A) Do you have a communicable disease, physical or mental disorder, or are you a drug abuser or addict? *
Under United States law communicable diseases of public health significance include:
- Granuloma inguinale
- Leprosy, infectious
- Lymphogranuloma venereum
- Syphilis, infectious stage
- Tuberculosis, active
- And others as determined by the Department of Health and Human Services.
Physical or Mental Disorders
With regard to physical or mental disorders, answer ”Yes” to this question if:
(a) You currently have a physical or mental disorder and a history of behavior associated with the disorder that may pose or has posed a threat to your property, safety or welfare or that of others; or
(b) You had a physical or mental disorder and a history of behavior associated with the disorder that has posed a threat to your property, safety or welfare or that of others and the behavior is likely to recur or lead to other harmful behavior.
Answer ”No” if:
(a) You currently have no physical or mental disorders; or
(b) You have or had a physical or mental disorder without associated behavior that may pose or has posed a threat to your property, safety or welfare of that of others; or
(c) You currently have a physical or mental disorder with associated behavior, but that behavior has not posed, does not currently pose nor will pose a threat to your property, safety or welfare or that of others; or
(d) You had a physical or mental disorder with associated behavior that posed a threat to your property, safety or welfare or that of others, but that behavior is unlikely to recur.
Drug Abusers and Drug Addicts
Under United States law persons may not be admissible if they have been determined to be a drug abuser or drug addict.
For further information refer to § 212(a)(1)(A) of the Immigration and Nationality Act, 8 U.S.C. § 1182(a)(1)(A), and corresponding regulations in the Code of Federal Regulations.
G) Have you ever asserted immunity from prosecution? *
With regard to immunity from prosecution, answer "Yes" to this question if all of the following apply:
(a) you have committed a serious criminal offense in the United States as defined in 8 U.S.C. Sec. 1101(h), including any felony, at any time for which immunity from criminal jurisdiction was exercised; and
(b) as a consequence of the offense and exercise of immunity identified in (a), you have departed from the United States; and
(c) you have not subsequently submitted fully to the jurisdiction of the court in the United States having jurisdiction with respect to that offense.
For further information refer to §212(a)(2)(E) and 101(h) of the Immigration and Nationality Act, 8 U.S.C. § 1182(a)(2)(E) and 1101(h).
I, the applicant, hereby certify that I have read, or have had read to me, all the questions and statements on this application and understand all the questions and statements on this application. The answers and information furnished in this application are true and correct to the best of my knowledge and belief.
By clicking on Continue to Review and Pay button, I certify that I have read and understood the above questions.