(Please read instructions on Page 2 and 3.)
File No. A-
I hereby apply to the Secretary of Homeland Security for permission to enter the United States temporarily under the provisions of section
212(d)(3) of the Immigration and Nationality Act (INA).
2. Date of Birth (mm/dd/yyyy)
1. Full Name (Print)
3. Place of Birth (City-Town, State/Province, Country)
4. Present Citizenship/Nationality
5. Present Address
6. All Addresses at which I have resided during the past five years. (Use separate sheet of paper, if necessary.)
8. Means of Transportation
10. Approximate Length of Stay in the United States.
9. Proposed Date of Entry
11. My purpose for entering the United States is: (Explain fully)
12. I believe I may be inadmissible to the United States for the following reasons and no others:
have not previously filed an application for advance permission to enter as a nonimmigrant
14. I understand that the information herein contained may be used in any proceedings (including civil or criminal judicial proceedings, or deportation
or removal proceedings) hereafter instituted against me.
I certify that the statements above and all attachments hereto are true and correct to the best of my knowledge and belief.
Signature of person preparing form, if other than applicant.
I declare that this document was prepared by me at the request of the applicant and is based on all information of which I have any knowledge.
(Signature of Applicant)
I-192, Application for Advance
Permission to Enter as Nonimmigrant
[Pursuant to Section 212(d)(3) of the INA]
OMB No. 1615-0017; Expires 09/30/08
Department of Homeland Security
U.S. Citizenship and Immigration Services
7. Desired Port of Entry into the United States.
Form I-192 (Rev. 07/30/07)Y