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Form 1-94W, Nonimmigrant Visa Waiver and Arrival and Departure Record

In the case of being a nonimmigrant visitor to the United States of America that doesn’t have a visitor visa, the following form has to be completed and submitted.


Extracted Text for Proper Search

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.
U.S. Customs and Border Protection 	OMB No. 1651-0111	
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 par ts. Please complete both the Arrival Record (Items 1 through 16) and 
the Depar ture Record (Items 19 through 22). The reverse side of this form must be signed 
and dated. Children under the age of four teen must have their form signed by a parent or 
Item 10 - 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.	
Admission Number
Arrival Record
Government Use Only	17. 18 .
CBP Form I-94W (11/11)O M B N o. 16 51- 0111	
Admission Number
Departure Record
CBP Form I-94W (11/11)	
See Other Side 14. City and State
16. Email Address
15. Telephone Number in the U.S. Where You Can be Reached	
1. Family Name
2. First (Given) Name
3. Birth Date (DD/MM/YY)
4. Country of Citizenship 5. Sex (Male or Female)
7. Passport Issue Date (DD/MM/YY) 8. Passport Expiration Date (DD/MM/YY)
9. Passport Number 10. Airline and Flight Number
11. Country Where You Live 12. City Where You Boarded
13. Address While in the United States (Number and Street) 6. Country of Birth
19. Family Name
20. First (Given) Name 21. Birth Date (DD/MM/YY)
22. Country of Citizenship	
 I-94W English (11-11) FINAL.indd   1	12/5/11   10:36 AM

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, Office of Regulations and Rulings, 799 Ninth Street NW, 
Washington, DC 20229.
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 you 
a drug abuser or addict? Ye s
B.  Have you ever been arrested or convicted for an offense or crime involving 
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 
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 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. 
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. visa cancelled? If yes, when? ______________________ where? 
G.  Have you ever asserted immunity from prosecution?
IMPORTANT:  If you answered “ Ye s ”  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)	
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.	
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 Immigr\
ation and Nationality Act.
Flight No./Ship Name:	
Date of Bir th First Name
Country of Citizenship	
Ye s No
Ye s No
Ye s No
Ye s No
Ye s No
Ye s No	
 I-94W English (11-11) FINAL.indd   2	12/5/11   10:36 AM
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