About this Document:

Accurate completion of this information by each passenger is required by US Customs and Immigrations prior to your departure from the United States. Please review and fill out the following form. You will be reminded to fill out any uncompleted field before the form can be submitted.

 


Identify and Describe yourself:

First Name

Last Name

Middle Initial

Gender

Male Female


US Address:
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code

Destination:
Destination

Citizenship:

Country of Citizenship:

USA
Other

Country of Residence:



Date of Birth:

-- mm/dd/yy


Emergency contact information:
Name
 Phone Number

Document information:

Type of documentation used for entry:

Passport
Visa
Alien Registration Card (Green card)
Birth Certificate
Affidavit
Certificate of Naturalization

Document number:



Document information:

Country issued from:


Document issue date:

-- mm/dd/yy

Document expiration date:

-- mm/dd/yy



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