Form I 192 – Fill Out and Use This PDF

Application for Advance Permission to Enter

as a Nonimmigrant

USCIS

Received

Returned Trans. Out

Fee Stamp

Trans. In

Completed

		Ground of Inadmissibility
	INA 212(a)(1)			INA 212(a)(9)
	INA 212(a)(2)			INA 212(a)(10)
INA 212(a)(3)				Other:
				Granted, subject to revocation at any time,
	INA 212(a)(4)
				upon the following terms and conditions
	INA 212(a)(6)
	INA 212(a)(7)
	INA 212(a)(8)

Action Stamp

Benefits Category:

Nonimmigrant other than T or U nonimmigrant/Advance Permission under INA 212(d)(3)(A) and 8 CFR 212.4

T Nonimmigrant/Advance Permission under INA 212(d)(3) and 8 CFR 212.16

T Nonimmigrant/Waiver under INA 212(d)(13) and 8 CFR 212.16

U Nonimmigrant/Waiver under INA 212(d)(14) and 8 CFR 212.17

U Nonimmigrant/Advance Permission under INA 212(d)(3)(A) and 8 CFR 212.17

Select this box if Form G-28 or Form G-28I is attached.

Volag Number

(if any)

Attorney State Bar Number

(if applicable)

Attorney or Accredited Representative USCIS Online Account Number (if any)

Part 1. Application Type

I am applying to the Secretary of Homeland Security for permission to enter the United States temporarily under the provisions of the Immigration and Nationality Act (INA) section 212(d)(3)(A)(ii), section 212(d)(13), or section 212(d)(14).

I am seeking this permission so that I may obtain (select only one box):

1. Admission as a nonimmigrant (other than as a T or U nonimmigrant).

2. Status as a victim of trafficking (T nonimmigrant status) or a victim of a crime (U nonimmigrant status).

Part 2. Information About You

Your Full Name

1.a. Family Name

(Last Name)

1.b. Given Name

(First Name)

1.c. Middle Name

Part 2. Information About You (continued)

Other Names Used (if any)

Provide all other names you have ever used, including aliases, maiden name, and nicknames. If you need extra space to complete this section, use the space provided in Part 8. Additional Information.

2.a. Family Name

(Last Name)

2.b. Given Name

(First Name)

2.c. Middle Name

3.a. Family Name

(Last Name)

3.b. Given Name

(First Name)

3.c. Middle Name

Other Information

4.Alien Registration Number (A-Number) (if any)

► A-

5.USCIS Online Account Number (if any)

►

6.Date of Birth (mm/dd/yyyy)

7.Gender Male Female

Place of Birth

8.a. City or Town

8.b. State or Province

8.c. Country

9.Country of Citizenship or Nationality

Mailing Address

10.a. In Care Of Name (if any)

10.b. Street Number

and Name

10.c.	Apt.		Ste.		Flr.
10.d.	City or Town
10.e.	State			10.f.	ZIP Code
10.g.	Province
10.h.	Postal Code
10.i.	Country

Safe Mailing Address

If you are a T or U visa applicant, and do not want U.S. Citizenship and Immigration Services (USCIS) to send notices about this application to your home, you may provide a safe mailing address.

11.a. In Care Of Name (if any)

11.b. Organization Name (if applicable)

11.c. Street Number

and Name

11.d.	Apt.			Ste.		Flr.
11.e.	City or Town
11.f.	State				11.g. ZIP Code
11.h.	Province
11.i.	Postal Code
11.j.	Country

Part 2. Information About You (continued)

Address History

Provide physical addresses for everywhere you have lived during the last five years, whether inside or outside the United States. Provide your current address first. If you need extra space to complete this section, use the space provided in Part 8. Additional Information.

Physical Address 1 (current address)

12.a. Street Number

and Name

12.b.	Apt.	Ste.		Flr.
12.c.	City or Town

Physical Address 3
16.a. Street Number
	and Name
16.b.	Apt.		Ste.		Flr.
16.c.	City or Town
16.d.	State			16.e. ZIP Code
16.f.	Province
16.g.	Postal Code
16.h.	Country

Dates of Residence

12.d. State

12.f. Province

12.g. Postal Code 12.h. Country

12.e. ZIP Code

17.a. From (mm/dd/yyyy)

17.b. To (mm/dd/yyyy)

Physical Address 4

18.a. Street Number

and Name

Dates of Residence

13.a. From (mm/dd/yyyy)

13.b. To (mm/dd/yyyy)	PRESENT

Physical Address 2

14.a. Street Number

and Name

14.b.	Apt.		Ste.		Flr.
14.c.	City or Town
14.d.	State			14.e. ZIP Code
14.f.	Province
14.g.	Postal Code
14.h.	Country

Dates of Residence

15.a. From (mm/dd/yyyy)

15.b. To (mm/dd/yyyy)

18.b.	Apt.			Ste.		Flr.
18.c.	City or Town
18.d.	State				18.e. ZIP Code
18.f.	Province
18.g.	Postal Code
18.h.	Country

Dates of Residence

19.a. From (mm/dd/yyyy)

19.b. To (mm/dd/yyyy)

Part 2. Information About You (continued)

Travel Information

NOTE: If you are applying for T or U nonimmigrant status and are in the United States, you may skip Item Numbers 20. - 25.

Location at Which you Plan to Enter the United States (desired Port-of-Entry)

20.a. City

20.b. State

21.Name of Port-of-Entry

22.How do you plan to travel to the United States? (For example, by plane, ship, car)

23.When do you plan to enter the United States? (mm/dd/yyyy)

24.Approximate Length of Stay in the United States

25.What is the purpose of your stay in the United States? Explain fully below.

Immigration and Criminal History

26.Do you believe that you may be inadmissible to the

United States?	Yes	No

If you answered "Yes" to Item Number 26., explain the reasons why you believe, according to the best of your knowledge, that you may be inadmissible in Part 8. Additional Information. If you were told that you are inadmissible, provide the reason you were given.

27.Have you previously filed an application for advance permission to enter the United States as a nonimmigrant?

Yes

No

If you answered "Yes" to Item Number 27., provide the details in Item Numbers 28. - 29.e. If you need extra space to complete this section, use the space provided in Part 8. Additional Information.

28.Date Application Filed (mm/dd/yyyy)

Location where you filed your application (for example, USCIS Office or Port-of-Entry).

29.a. USCIS Office or U.S. Port-of-Entry

29.b. City or Town

29.c. State or Province

29.d. Country

29.e. Receipt Number (if available)

►

30.Have you EVER been in the United States for a period of

six months or more?	Yes	No

If you answered "Yes" to Item Number 30., provide the dates you were in the United States (from and to) and your immigration status at the time of entry into the United States in the space provided in Part 8. Additional Information.

31.Have you EVER filed an application or petition for immigration benefits with the U.S. Government, or has

one ever been filed on your behalf?	Yes	No

If you answered "Yes" to Item Number 31., provide the information requested in Item Numbers 32.a. - 32.c.

If you (or somebody else on your behalf) have filed multiple applications or petitions for immigration benefits with the U.S. Government, use the space provided in Part 8. Additional Information to provide the answers to Item Numbers

32.a. - 32.c. for each of your additional applications or petitions. 32.a. Type of Application or Petition Filed

32.b. Location Where You (or the Other Person) Filed the Application or Petition (for example, USCIS office or Port-of-Entry);

32.c. Outcome of the Application or Petition (for example, approved, denied, or is pending).

Part 2. Information About You (continued)

33.Have you EVER been denied or refused an immigration benefit by the U.S. Government, or had a benefit revoked or terminated (including but not limited to visas)?

Yes No

If you answered "Yes" to Item Number 33., provide an explanation the information in the space provided in Part 8. Additional Information.

34.Have you EVER, in or outside the United States, been arrested, cited, charged, indicted, fined, convicted, or imprisoned for breaking or violating any law or ordinance, excluding minor traffic violations?

Yes No

If you answered "Yes" to Item Number 34., describe the incidents in detail and include all offenses where impaired driving may have been an issue in the space provided in Part 8. Additional Information.

Part 3. Biographic Information

1.Ethnicity (Select only one box)

Hispanic or Latino

Not Hispanic or Latino

2.Race (Select all applicable boxes)

American Indian or Alaska Native

Asian

Black or African American

	Native Hawaiian or Other Pacific Islander
	White
3.	Height	Feet	Inches

Part 4. Other Information About You

Employment History

Provide your employment history for the last five years, whether inside or outside the United States. Provide the most recent employment first. If you need extra space to complete this section, use the space provided in Part 8. Additional Information.

Employer 1 (current or most recent)

1.Name of Employer or Company

Address of Employer or Company

2.a. Street Number

and Name

2.b. Apt. Ste. Flr.

2.c. City or Town

2.d. State		2.e. ZIP Code

2.f. Province

2.g. Postal Code

2.h. Country

3.Your Occupation

Dates of Employment

4.a. From (mm/dd/yyyy)

4.b. To (mm/dd/yyyy)

4.Weight

5.Eye Color (Select only one box)

Black	Blue
Gray	Green
Maroon	Pink

6.Hair Color (Select only one box)

Bald (No hair)	Black
Brown	Gray
Sandy	White

Pounds

Brown

Hazel

Unknown/Other

Blond

Red

Unknown/Other