GENERAL INFORMATION

Family Name *


First (Given) Name *


Are you known by any other names or aliases? *
No   Yes

Family Name *

First (Given) Name *




Gender *
Male   Female

Date of Birth *


City of Birth *


Country of Birth *


Country of Citizenship *


CONTACT INFORMATION

E-mail Address *


Confirm E-mail Address

Telephone Type *


Country Code + Phone *

Address Line 1 *


Address Line 2


Apartment Number


City *


State/Province/Region *


Country *


SOCIAL MEDIA (OPTIONAL)
Please enter information associated with your online presence.

Provider / Platform

Social Media Identifier




PARENTS INFORMATION

Father's Family Name *


Father's First (Given) Name *


Mother's Family Name *


Mother's First (Given) Name *



PASSPORT INFORMATION

Passport Number *


Issuing Country *



Issuance Date *

Expiration Date *

National Identification Number *
Personal Identification Number *


Have you ever been issued a passport or national identity card for travel by any other country? *
No   Yes  

Issuing Country *


Document Type *


Document Number *

Year Expiration Date *



Are you now, a citizen or national of any other country? *
No   Yes  

Country of Citizenship / Nationality *


How did you acquire citizenship / nationality from this country? *


Other *


Have you ever been a citizen or national of any other country? *
No   Yes  

Country of Citizenship / Nationality *


You have indicated that you are not a citizen or national of your country of birth.
From the list below, please select ALL statements that apply with respect to your country of birth:
Did not acquire citizenship at birth or have never held citizenship in birth country
Renounced citizenship of birth country
Have not lived or resided in birth country within the past five years
Have not held a passport or national identity card from birth country within the past five years
Other

GE MEMBERSHIP
Are you a member of the CBP Global Entry Program? *
No   Yes

PASSID / Membership Number *

EMERGENCY CONTACT INFORMATION IN OR OUT OF THE U.S.

Family Name *


First (Given) Name *


Country Code + Phone *




E-mail Address



EMPLOYMENT INFORMATION

Do you have a current or previous employer? *
No   Yes

Job Title *


Employer Name *


Address Line 1 *


Address Line 2


City *


State/Province/Region *


Country *


Country Code + Phone





ELIGIBILITY QUESTIONS
Social And Medical Information

1) Do you have a physical or mental disorder; or are you a drug abuser or addict; 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): *
  • Cholera
  • Diphtheria
  • Tuberculosis, infectious
  • Plague
  • Smallpox
  • Yellow Fever
  • Viral Hemorrhagic Fevers, including Ebola, Lassa, Marburg, Crimean-Congo
  • Severe acute respiratory illnesses capable of transmission to other persons and likely to cause mortality.
No    Yes
2) 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? *
No    Yes

3) Have you ever violated any law related to possessing, using, or distributing illegal drugs? *
No    Yes

4) Do you seek to engage in or have you ever engaged in terrorist activities, espionage, sabotage, or genocide? *
No    Yes
5) 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? *
No    Yes

6) 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? *
No    Yes

7) 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? *
No    Yes

Where *


When *


8) Have you ever stayed in the United States longer than the admission period granted to you by the U.S. government? *
No    Yes

9) Have you traveled to, or been present in Iraq, Syria, Iran, or Sudan on or after March 1, 2011? *
No    Yes

Select country:
From:
To:

Select the reason from the list:


ENTER TRAVEL INFORMATION
U.S. Point Of Contact Information

Is your travel to the U.S. occurring in transit to another country? *
No   Yes  

Name *


Address Line 1 *


Address Line 2


Apartment Number


City *


State *


Phone Number *


Address While In The U.S.

Can be same as above

Address Line 1 *


Address Line 2


Apartment Number


City *


State *



Verification *
For verification purposes, please re-enter the following information, as shown on your ESTA-eligible passport.
Confirm your date of birth. *


Confirm your passport number. *

Confirm your passport issuance date. *


Confirm your passport expiration date. *

Certification
I, the applicant, hereby certify that I have read, or have 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 provided by me in this application are true and correct to the best of my knowledge and belief.

PLEASE NOTE
To proceed click 'Submit Application For U.S. Travel' below, this will take you to Payment Page. You have a choice of payment method. If you choose PayPal, you do not need an account with PayPal.
The cost is USD $79.00, you will need a Credit Card or Debit Card to make payment.

Step 2: Review Your Details
Please review all information for accuracy before submitting your application. If information is inaccurate, please make corrections. Select "Submit Application For U.S. Travel" if/when all information is correct.