Applicant Information

Your Name (Or Aliases) Details

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Your Passport (Or Travel Documents) Details

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Other Citizenships or Nationality

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Parents Details

Travel Information

Your Contact Infos

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Emergency Contact info in the U.S. or ABROAD

Employment Information

Eligibility Questions

Travel Infos

Eligibility Questions

  • 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.
Disclaimers

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. -or- THIRD PARTY CERTIFICATION [ ] 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.

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