ESTA application Visa form for the USA

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ESTA Application

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Verification

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File Number

Payment

ESTA FORM

Family Name *

- Enter your family name as the family name appears on your passport under the Family Name or Surname field. The family name is required to complete the application.

First (Given) Name *

- Enter your first (given) name as the first name appears on your passport under the First or Given Name field. Do not include the middle name in this field. First name is required to complete the application. If you have no first name, then enter the letters FNU which stands for First Name Unknown.

Are you known by any other names or aliases?*

- Indicate whether you are known by any other names or aliases by selecting yes or no. Answering this question is required to complete your application.

Yes No

Other Names/Aliases*

- Enter up to 10 other names or aliases by which you are known if you selected "yes" to the previous question. At least one entry is required to complete the application. For each alias: In the Family Name field, enter your alternate family name. The family name is required to complete the application. In the First (Given) Name field, enter your alternate first (given) name. Do not include the middle name in this field. The first name is required to complete the application. If you have no alternate first name, then enter the letters FNU which stands for First Name Unknown.

Country of Citizenship *

- Choose the country of citizenship, as it appears on your passport. The passport issuing country is required to complete the application.

City of Birth*

- Enter the city, town, village, or hamlet in which you were born. The city, town, village, or hamlet where you were born is required to complete the application. If you do not know the city in which you were born, enter UNKNOWN.

Country of birth *

- Choose the country in which you were born. The country where you were born is required to complete the application.

Residential country *

- Choose the country in which you reside. The country where you live is required to complete the application.

Are you a citizen of any other country?*

- Indicate whether you are a citizen of any other country. Answering this question is required to complete your application.

Yes No

Other Citizenship*

- In the Country field, choose the country of your other citizenship(s). If you answered yes above, the country is required to complete your application. In the Passport Number field, enter your passport number as it appears in your other passport(s). The passport number may contain numbers and/or characters. Please closely distinguish between the two, such as the numbers zero and one, and the letters O and I. The passport number is optional to complete your application.

Country

Passport Number

Parents*

- Enter the names of your parents. These are required to complete the application. If you do not know the name of one or both of your parents, enter UNKNOWN, for each parent. This field can include the names of your biological, adoptive, step-parent or guardian. In the Family Name field, enter your parent's family name. The family name is required to complete the application. If you do not know one or both of your parents, enter UNKNOWN. In the First (Given) Name field, enter your parent's first (given) name. Do not include the middle name in this field. The first name is required to complete the application. If your parent has no first name, or if you do not know one or both of your parents, enter UNKNOWN.

Birth Date

Day *

- Choose the day on which you were born. The day of birth is required to complete the application or to check the status of your application.

Month *

- Choose the month in which you were born. The month of birth is required to complete the application or to check the status of your application.

Year *

- Choose the year in which you were born. The year of birth is required to complete the application or to check the status of your application.

Sex *

- Choose your gender, either male or female. The sex (gender) is required to complete the application.

Male Female

E-Mail Address *

- Enter the e-mail address at which you can be contacted. The e-mail address is optional to complete the application.

Home Address

Address line 1*

- In the Address Line 1 field, enter the number and street of the location of your home address. Do not include the city and state in this field. Address line 1 is required to complete the application.

Address Line 2

City*

- In the City field, enter the city, town, village, or hamlet. The city, town, village, or hamlet is required to complete the application.

Country*

- In the Country field, choose the country. The country is required to complete the application.

Telephone Number

Telephone Type*

Country Code *

- Choose the country code of the telephone number where you can be contacted. The country code and telephone number are optional to complete the application.

Number *

- Enter the telephone number where you may be contacted. The telephone number is optional to complete the application.

Passport Information

Passport Number *

- Enter your passport number as it appears on your passport. The passport number may contain numbers and/or characters. Please closely distinguish between the number zero and the letter O. The passport number is required to complete the application or to check the status of your application.

Passport Issuing Country (Country of Citizenship) *

- Choose the country of citizenship, as it appears on your passport. The passport issuing country is required to complete the application.

Passport Issuance Date

Day *

- Choose the day on which your passport was issued, as it appears on your passport under the Date of Issue field. The day on which the passport was issued is required to complete the application.

Month *

- Choose the month in which your passport was issued, as it appears on your passport under the Date of Issue field. The month in which the passport was issued is required to complete the application.

Year *

- Choose the year in which your passport was issued, as it appears on your passport under the Date of Issue field. The year in which the passport was issued is required to complete the application.

Passport Expiration Date

Day *

- Choose the day on which your passport expires, as it appears on your passport under the Expiration Date or Extension field. The day on which the passport expires is required to complete the application.

Month *

- Choose the month in which your passport expires, as it appears on your passport under the Expiration Date or Extension field. The month in which the passport expires is required to complete the application.

Year *

- Choose the year in which your passport expires, as it appears on your passport under the Expiration Date or Extension field. The year in which the passport expires is required to complete the application.

GE MEMBERSHIP

Global Entry is a program developed by US Customs and Border Protection to speed up the process of entry into the United States for low-risk, controlled international passengers prior. Upon arrival in the United States, program members move directly to the Global Entry Auto Binder, enabling them to bypass passport checkpoints and customs clearance papers.

Are you a member of the CBP Global Entry Program?

- Are you a member of the CBP Global Entry Program?

Yes No

PASSID / Membership Number

SOCIAL MEDIA (OPTIONAL)

- Enter information associated with your online presence, including the types of online platforms, applications and websites that you use to collaborate, share information, and interact with others, as well as the username(s) associated with those accounts. (OPTIONAL)

Provider / Plateform

- Select from the drop down list to identify each of the social media platforms that you use. (OPTIONAL)

Social Media Identifier

- List the username, handle, screen-name, or other identifier associated with your social media profile.

Travel Information

City Where You are Boarding

- Enter the last city where you will board an aircraft prior to arriving in the United States on this trip. The city where the applicant will board is optional to complete the application.

Flight or Ferry Information

Carrier Name

- Choose the carrier name for the carrier on which you will be traveling to the United States, if your travel information is available. The carrier name is optional to complete the application.

Flight Number or Ferry Name

- Enter the flight number or vessel name for the carrier on which you will be traveling to the United States, if your travel information is available. The flight number or vessel name is optional to complete the application.

Address While In The United States

Address Line 1

- Enter the number and street of the location where you will stay while in the United States. Do not include the city and state in this field. The address is optional to complete the application. • If multiple locations are planned, enter the first address. • If the complete address is not known, enter the name of the hotel or location you will visit. You may update this information once confirmed. • If you are leaving the United States immediately and do not have an address, enter the words ”In Transit” and your final destination location.

Address Line 2

- Enter apartment, suite, unit, floor, building, or other, if appropriate. Do not include the city and state in this field. Address line 2 is optional to complete the application.

City

- Enter the city of the address where you will stay while in the United States. The city is optional to complete the application.

State

- Enter the state of the address where you will stay while in the United States. The state is optional to complete the application.

Emergency Contact Information In or Out of the United States

Family Name *

- Enter your emergency point of contact who may be a person in or outside of the United States, e.g., a family member, friend, or business associate. In the Family Name field, enter your emergency contact’s family name. You must complete this field to complete the application. If you have no emergency contact, enter UNKNOWN.

First (Given) Name *

- Enter your emergency point of contact who may be a person in or outside of the United States, e.g., a family member, friend, or business associate. In the First (Given) Name field, enter the emergency contact’s first name. You must complete this field to complete the application. If you have no emergency contact (or your contact has only one name), enter UNKNOWN.

E-Mail Address *

- Enter your emergency contact's e-mail address. E-mail address is required to complete the application. You may also enter UNKNOWN.

Telephone Number

Country Code *

- In the Country Code field, enter the country code of your emergency contact's telephone number. The country code is required to complete the application. If you do not have an emergency contact telephone country code you may enter zeros.

Number *

- In the Number field, enter your emergency contact's telephone number. The number is required to complete the application. If you do not have an emergency contact telephone number you may enter zeros.

Travel Information

Is your travel to the US occurring in transit to another country? *

- Indicate whether your travel to the US is occurring in transit to another country by selecting yes or no. Answering this question is required to complete your application.

Yes No

US Point of Contact Information

US Point of Contact*

- A U.S. point of contact may be a friend, relative, or business associate. If you do not have a U.S. point of contact, please enter the name, address and telephone number of the location where you will be staying (e.g. a hotel name). You may also enter UNKNOWN.

Address line 1*

Address Line 2

City*

Telephone Number*

Employment Information

Do you have a current or previous employer?*

- Indicate whether you have a current or previous employer by selecting yes or no. Answering this question is required to complete your application.

Yes No

Employer Name*

- Enter the name of your current employer. If you are not currently employed, enter the name of your previous employer. Employer name is required to complete the application. You may also enter SELF-EMPLOYED, STUDENT, CHILD, HOMEMAKER, STAY-AT-HOME PARENT, or any other word to describe your employment status.

Job Title

- Enter the job title of your current or previous employment. Job title is optional to complete this application.

Telephone Number

Address

Address line 1*

Address Line 2

City*

Country*

Do any of the following apply to you? (Answer Yes or No)

1) Do you have a physical or mental disorder; or are you a drug abuser or addict; or do you currently have any of the following diseases (communicable diseases are specified pursuant to section 361(b) of the Public Health Service Act):

Cholera
Diphtheria
Tuberculosis, infectious
Plague
Smallpox
Yellow Fever
Viral Hemorrhagic Fevers, including Ebola, Lassa, Marburg, Crimean-Congo
Severe acute respiratory illnesses capable of transmission to other persons and likely to cause mortality.

Yes No

2) Have you ever been arrested or convicted for a crime that resulted in serious damage to property, or serious harm to another person or government authority?*

Yes No

3) Have you ever violated any law related to possessing, using, or distributing illegal drugs?*

Yes No

4) Do you seek to engage in or have you ever engaged in terrorist activities, espionage, sabotage, or genocide?*

Yes No

5) Have you ever committed fraud or misrepresented yourself or others to obtain, or assist others to obtain, a visa or entry into the United States?*

Yes No

6) Are you currently seeking employment in the United States or were you previously employed in the United States without prior permission from the U.S. government?*

Yes No

7) Have you ever been denied a U.S. visa you applied for with your current or previous passport, or have you ever been refused admission to the United States or withdrawn your application for admission at a U.S. port of entry?*

Yes No

when*

where*

8) Have you ever stayed in the United States longer than the admission period granted to you by the U.S. government?*

Yes No

9) Have you traveled to, or been present in Iraq, Syria, Iran, Sudan, Libya, Somalia or Yemen on or after March 1, 2011?*

Yes No

Waiver of Rights: I have read and understand that I hereby waive for the duration of my travel authorization obtained via ESTA 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 removal action arising from an application for admission under the Visa Waiver Program.

In addition to the above waiver, as a condition of each admission into the United States under the Visa Waiver Program, I agree that the submission of biometric identifiers (including fingerprints and photographs) during processing upon arrival in the United States shall reaffirm my waiver of 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 removal action arising from an application for admission under the Visa Waiver Program.

* Certification: I, the applicant, hereby certify that I have read, or have had read to me, all the questions and statements on this application and understand all the questions and statements on this application. The answers and information furnished in this application are true and correct to the best of my knowledge and belief.

For third-parties submitting the application on behalf of the applicant, I hereby certify that I have read to the individual whose name appears on this application (applicant) all the questions and statements on this application. I further certify that the applicant certifies that he or she has read, or has had read to him or her, all the questions and statements on this application, understands all the questions and statements on this application, and waives any rights to review or appeal of a U.S. Customs and Border Protection Officer's determination as to his or her admissibility, or to contest, other than on the basis of an application for asylum, any removal action arising from an application for admission under the Visa Waiver Program.

The answers and information furnished in this application are true and correct to the best of the applicant's knowledge and belief.

* I accept the terms and conditions

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