Mailing Address: First Name
Middle Name(s)
Last Name
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Mailing Street Address
Apt/Ste./Flr number
City
Province
Postal Code
Country
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 Additional Information. Family Name (Last Name)
Given Name (First Name)
Family Name (Last Name)
Additional Information
Other Information: Alien Registration Number (A-Number) (if any)
USCIS Online Account Number (if any)
Date of Birth (mm/dd/yyyy)
Gender
Place of Birth: City or Town
State or Province
Country of Citizenship or Nationality
Address History Provide physical addresses for everywhere you have lived during the last five years, whether inside or outside the United States. Also provide the dates of residence, indicating when you lived at the location listed. If you are unsure of the exact date, provide the closest approximate date to the best of your knowledge. Provide your current address first.
Travel Information Location at Which you Plan to Enter the United States (desired Port-of-Entry)
State
Port-of-Entry
How do you plan to travel to the United States?
When do you plan to travel to the United States?
Approximate length of stay in the United States?
What is the purpose of your stay in the United States?
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