3. Date of Birth (mm/dd/yyyy)

Have you ever used any other date of birth?

Yes No

4. Do you have an Alien Registration Number (A-Number)?

Yes No

5. Have you ever used, or been assigned, any other A-Number?

Yes No

6. Sex

Male Female

7. Place of Birth

8. Country of Citizenship or Nationality

9. USCIS Online Account Number (if any) If one has been assigned, you can find it on a notice that USCIS may have sent to you.

10. Recent Immigration History

If you last entered the United States using a passport or travel document, provide the following information.

Passport or Travel Document Number Used at Last Arrival Expiration Date of this Passport or Travel Document (mm/dd/yyyy) Country that Issued this Passport or Travel Document Nonimmigrant Visa Number Used During Most Recent Arrival (if any) Date Nonimmigrant Visa Was Issued (mm/dd/yyyy)

Place and Date of Last Arrival into the United States

11. When I last arrived in the United States:

12. If you were issued a Form I-94 Arrival/Departure Record, provide the information from your most recent Form I-94 below:

Form I-94 Arrival/Departure Record Number Expiration Date of Authorized Stay (mm/dd/yyyy) or type “D/S” Immigration Status on Form I-94

13. Was your last arrival the first time you were physically present in the United States?

Yes No

14. What is your current immigration status (if it has changed since your last arrival)?

15. Expiration Date of Current Immigration Status (mm/dd/yyyy) or “D/S”

16. Have you ever been issued an “alien crewman” visa?

Yes No

17. Did you last arrive in the United States to join a vessel or aircraft as a crewman?

Yes No