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Applicant Information

  • First Name:
  • Gender:
  • Place of Birth:
  • Mother's Name:
  • Father's Name:
  • Family Name:
  • Birth Date:
    --
  • Country of Birth:
  • Mother's Last Name:
  • Father's Last Name:

Contact Information

  • E-mail Address:
  • Telephone Number:
  • Address Line:
  • City:
  • State/Province/Region:
  • Country:

Employment Information

  • Do you have a current or previous employer?:
    No
  • Job Title:
  • Employer Name:
  • Address Line:
  • Post Code:
  • City:
  • State/Province/Region:
  • Country:
  • Phone:

Travel Information

  • Is your travel to the US occurring in transit to another country?:
    No

Passport Information

  • Country Passport:
  • Issuing Country:
  • Passport number:
  • Passport Date of Issue:
    --
  • Expiration date:
    --
  • Have you ever been issued a passport or national identity card for travel by any other country?:
    No
  • Issuing Country:
  • Document Type:
  • Document Number:
  • Expiration date:
    --
  • Are you now, a citizen or national of any other country?:
    No
  • Country of Citizenship / Nationality:
  • How did you acquire citizenship / nationality from this country?:
  • Have you ever been a citizen or national of any other country?:
    No
  • Country of Citizenship / Nationality:

GE Membership

  • Are you a member of the CBP Global Entry Program?:
    No

Do any of the following apply to you? (Change to Yes if applicable)

  • Do you have any physical or mental disorder? or you are a drug addict or addict; or do you currently have any of the following diseases:
    No
  • 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?:
    No
  • Have you ever violated any law related to possessing, using, or distributing illegal drugs?:
    No
  • Do you seek to engage in or have you ever engaged in terrorist activities, espionage, sabotage, or genocide?:
    No
  • 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?:
    No
  • 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?:
    No
  • 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?:
    No
  • Have you ever stayed in the United States longer than the admission period granted to you by the U.S. government?:
    No
  • Have you traveled to, or been present in Iraq, Syria, Iran, Sudan, Libya, Somalia or Yemen on or after March 1, 2011?:
    No
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