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

Part 4. Other Information About You (continued)

Employer 2

5.Name of Employer or Company

Address of Employer or Company

6.a.	Street Number
	and Name
6.b.	Apt.	Ste.		Flr.

14.Current City or Town of Residence (if living)

15.Current Country of Residence (if living)

Information About Your Father

Father's Legal Name

16.a. Family Name

(Last Name)

6.c. City or Town

6.d. State

6.f. Province

6.g. Postal Code 6.h. Country

6.e. ZIP Code

16.b. Given Name

(First Name)

16.c. Middle Name

Father's Name at Birth (if different than above)

17.a. Family Name

(Last Name)

17.b. Given Name

(First Name)

17.c. Middle Name

7.Your Occupation

Dates of Employment

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

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

Information About Your Parents

Information About Your Mother

Mother's Legal Name

9.a. Family Name

(Last Name)

9.b. Given Name

(First Name)

9.c. Middle Name

Mother's Name at Birth (if different than above)

10.a. Family Name

(Last Name)

10.b. Given Name

(First Name)

10.c. Middle Name

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

12.City or Town of Birth

13.Country of Birth

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

19.City or Town of Birth

20.Country of Birth

21.Current City or Town of Residence (if living)

22.Current Country of Residence (if living)

Information About Your Marital History

23.What is your current marital status?

Single, Never Married Married Divorced

Widowed

Legally Separated

Marriage Annulled Other

24. How many times have you been married (including annulled marriages and marriages to the same person)?

►

Part 4. Other Information About You (continued)

Information About Your Current Marriage

(including if you are legally separated)

If you are currently married, provide the following information about your current spouse.

Current Spouse's Legal Name

25.a. Family Name

(Last Name)

25.b. Given Name

(First Name)

25.c. Middle Name

26.A-Number (if any)

► A-

27.Current Spouse's Date of Birth (mm/dd/yyyy)

28.Date of Marriage to Current Spouse (mm/dd/yyyy)

Current Spouse's Place of Birth

29.a. City or Town

29.b. State or Province

29.c. Country

Place of Marriage to Current Spouse

30.a. City or Town

30.b. State or Province

30.c. Country

Information About Prior Marriages (if any)

If you have been married before, whether in the United States or in any other country, provide the information requested in Item Numbers 31.a. - 36.c. about your prior marriage. If you have had more than one previous marriage, use the space provided in Part 8. Additional Information to provide the answers to Item Numbers 31.a. - 36.c. for each additional marriage.

Prior Spouse's Legal Name (provide family name before marriage)

31.a. Family Name

(Last Name)

31.b. Given Name

(First Name)

31.c. Middle Name

32.Prior Spouse's Date of Birth (mm/dd/yyyy)

33.Date of Marriage to Prior Spouse (mm/dd/yyyy)

Place of Marriage to Prior Spouse

34.a. City or Town

34.b. State or Province

34.c. Country

35.Date Marriage with Prior Spouse Legally Ended

(mm/dd/yyyy)

Place Where Marriage with Prior Spouse Legally Ended

36.a. City or Town

36.b. State or Province

36.c. Country

Part 5. Applicant's Statement, Contact

Information, Declaration, Certification, and

Signature

NOTE: Read the Penalties section of the Form I-192 Instructions before completing this section.

Applicant's Statement

NOTE: Select the box for either Item Number 1.a. or 1.b. If applicable, select the box for Item Number 2.

1.a.	I can read and understand English, and I have read
	and understand every question and instruction on this
	application and my answer to every question.
1.b.	The interpreter named in Part 6. read to me every
	question and instruction on this application and my
	answer to every question in
		,
	a language in which I am fluent, and I understood
	everything.
2.	At my request, the preparer named in Part 7.,
		,

prepared this application for me based only upon information I provided or authorized.

I understand that DHS may require me to appear for an appointment to take my biometrics (fingerprints, photograph, and/or signature) and, at that time, if I am required to provide biometrics, I will be required to sign an oath reaffirming that:

1)I reviewed and understood all of the information contained in, and submitted with, my application; and

2)All of this information was complete, true, and correct at the time of filing.

I certify, under penalty of perjury, that all of the information in my application and any document submitted with it were provided or authorized by me, that I reviewed and understand all of the information contained in, and submitted with, my application and that all of this information is complete, true, and correct.

Applicant's Signature

6.a. Applicant's Signature

6.b. Date of Signature (mm/dd/yyyy)

NOTE TO ALL APPLICANTS: If you do not completely fill out this application or fail to submit required documents listed in the Instructions, USCIS may deny your application.

Applicant's Contact Information

3.Applicant's Daytime Telephone Number

4.Applicant's Mobile Telephone Number (if any)

5.Applicant's Email Address (if any)

Applicant's Declaration and Certification

Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that the U.S. Department of Homeland Security (DHS) may require that I submit original documents to DHS at a later date. Furthermore, I authorize the release of any information from any and all of my records that DHS may need to determine my eligibility for the immigration benefit that I seek.

I furthermore authorize release of information contained in this application, in supporting documents, and in my DHS records, to other entities and persons where necessary for the administration and enforcement of U.S. immigration law.

Part 6. Interpreter's Contact Information, Certification, and Signature

Provide the following information about the interpreter.

Interpreter's Full Name

1.a. Interpreter's Family Name (Last Name)

1.b. Interpreter's Given Name (First Name)

2.Interpreter's Business or Organization Name (if any)

Part 6. Interpreter's Contact Information, Certification, and Signature (continued)

Interpreter's Mailing Address

3.a. Street Number

and Name

3.b. Apt. Ste. Flr.

3.c. City or Town

3.d. State		3.e. ZIP Code

3.f. Province

3.g. Postal Code

3.h. Country

Interpreter's Contact Information

4.	Interpreter's Daytime Telephone Number

Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant

Provide the following information about the preparer.

Preparer's Full Name

1.a. Preparer's Family Name (Last Name)

1.b. Preparer's Given Name (First Name)

2.Preparer's Business or Organization Name (if any)

Preparer's Mailing Address

3.a. Street Number

and Name

3.b. Apt. Ste. Flr.

3.c. City or Town

5.	Interpreter's Mobile Telephone Number (if any)
6.	Interpreter's Email Address (if any)

Interpreter's Certification

I certify, under penalty of perjury, that:

3.d. State

3.f. Province

3.g. Postal Code 3.h. Country

3.e. ZIP Code

I am fluent in English and		,

which is the same language specified in Part 5., Item Number 1.b., and I have read to this applicant in the identified language every question and instruction on this application and his or her answer to every question. The applicant informed me that he or she understands every instruction, question, and answer on the application, including the Applicant's Declaration and Certification, and has verified the accuracy of every answer.

Interpreter's Signature

7.a. Interpreter's Signature

7.b. Date of Signature (mm/dd/yyyy)

Preparer's Contact Information

4.Preparer's Daytime Telephone Number

5.Preparer's Mobile Telephone Number (if any)

6.Preparer's Email Address (if any)

Part 8. Additional Information

If you need extra space to provide any additional information within this application, use the space below. If you need more space than what is provided, you may make copies of this page to complete and file with this application or attach a separate sheet of paper. Type or print your name and A-Number (if any) at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet.

1.a. Family Name

(Last Name)

1.b. Given Name

(First Name)

1.c. Middle Name

2. A-Number (if any)► A-

3.a. Page Number 3.b. Part Number 3.c. Item Number

3.d.

4.a. Page Number 4.b. Part Number 4.c. Item Number

4.d.

5.a. Page Number 5.b. Part Number 5.c. Item Number

5.d.

6.a. Page Number 6.b. Part Number 6.c. Item Number

6.d.

7.a. Page Number 7.b. Part Number 7.c. Item Number

7.d.