ESTA APPLICATION FORM

Applicant Information

All fields for the Applicant Information are required to process your ESTA application.

Family Name *

First Name *

Gender *

Male Female

Are you known by any other names or aliases? *

No: Yes:

Alias Family Name *

Alias First Name *

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Date Of Birth *

City of Birth *

Country of Birth *

Contact Information

Email *

Confirm Email

Country Code *

Phone *

Home Address *

Apartment Number

City *

State *

Country *

GE MEMBERSHIP

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

No Yes

PASSID / Membership Number *

Parent's Information

Father First Name *

Father Last Name *

Mother First Name *

Mother Last Name *

Passport Information

Passport Number *

Country of Citizenship *

Issuing Country *

Issuance Date *

Expiration Date *

National Identification Number *

Personal Identification Number *

Image *

Have you ever been issued a passport or national identity card for travel by any other country? *

No Yes

Issuing Country *

Document Type *

Document Number *

Expiration Year *

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Other Citizenship/Nationality

Are you now, a citizen or national of any other countries? *

No Yes

Country Name *

How did you acquire citizen / nationality from this country? *

Other Description

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Have you ever been a citizen or national of any other countries? *

No Yes

Country Name *

From *

To *

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Emergency Contact Information In or Outside the U.S.

Emergency Contact First Name *

Emergency Contact Last Name *

Country Code *

Emergency Contact Phone *

Emergency Contact Email *

Employment Information

Do you have a current or previous employer? *

No Yes

Employer Name *

Employer Address *

Employer City *

Employer State *

Employer Country *

Country Code

Employer Phone

Job Title

Security Information

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-Cong. Severe acute respiratory illnesses capable of transmission to other persons and likely to cause mortality. *

No Yes

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 Yes

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

No Yes

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

No Yes

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 Yes

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 Yes

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 Yes

When Visa Denied *

Where Visa Denied *

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

No Yes

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

No Yes

Travel Information

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

Yes No

U.S. Point of Contact Information

Point of Contact *

Contact Address *

Contact City *

Contact State *

Country Code *

Contact Phone *

Address While in USA

US Street

US City

US State

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.

ESTA APPLICATION FORM

Applicant Information

Contact Information

GE MEMBERSHIP

Parent's Information

Passport Information

Other Citizenship/Nationality

Emergency Contact Information In or Outside the U.S.

Employment Information

Security Information

Travel Information

U.S. Point of Contact Information

Address While in USA

Certification

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