DEPARTMENT OF HOMELAND SECURITY U.S. Customs and Border Protection
OMB No. 1651-0111
OMB No. 1651-0111
OMB No. 1651-0111
CBP Form I-94 (05/08)CBP Form I-94 (05/08)
CBP Form I-94 (05/08)
STAPLE HERE
See Other Side
Admission Number
Arrival Record
000000000 00
Admission Number
Departure Record
000000000 00
1. Family Name
2. First (Given) Name
3. Birth Date (DD/MM/YY)
4. Country of Citizenship
5. Sex (Male or Female)
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8. Passport Number 9. Airline and Flight Number 10. Country Where You Live 11. Country Where You Boarded
12. City Where Visa Was Issued
13. Date Issued (DD/MM/YY)
14. Address While in the United States (Number and Street)16. Telephone Number in the U.S. Where You Can be Reached 17. Email Address
18. Family Name 19. First (Given) Name 20. Birth Date (DD/MM/YY)
21. Country of Citizenship
DEPARTMENT OF HOMELAND SECURITY U.S. Customs and Border Protection
15. City and State
6. Passport Issue Date (DD/MM/YY)
7. Passport Expiration Date (DD/MM/YY)Welcome to the United States I-94 Arrival/Departure Record
Instructions
This form must be completed by all persons except U.S. Citizens, returning resident aliens, aliens with immigrant visas, and Canadian Citizens visiting or in transit.
Type or print legibly with pen in ALL CAPITAL LETTERS. Use English. Do not write on the back of thi
s form.
This form is in two parts. Please complete both the Arrival Record (Items 1 through 17) and the Departure Record (Items 18 through 21).
When all items are completed, present this form to the CBP Officer.
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.
I-94 Back 11” h x 4.5”w Fonts: Arial, Times
This Side For Government Use Only
Applicant’s
Name
End Secondary
Time Insp. #
Disposition
Date
Referred Time Insp. #
Other
Reason Referred
Secondary Inspection
Record of Changes
Departure Record Port:
Date:
Carrier:
Flight No./ Ship Name:
Primary Inspection
212A PP Visa Parole L/O TWOV
22. Occupation 23. Waivers
24. CIS A Number 25. CIS FCO
26. Petition Number 27. Program Number
28.        Bond 29.        Prospective Student
30. Itinerary/Comments
31. TWOV Ticket Number
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
A-
Warning  A nonimmigrant who accepts unauthorized employment is subject to deportation. 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
Students  planning  to  reenter  the  U.S.  within  30  days  to  return  to  the  same  school,  see
“Arrival-
Departure” on page 2 of Form I-20 prior to surrendering this permit.

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