APPLICANT DETAILS PARENTS DETAILS EMPLOYER DETAILS TRAVEL PLANS CONTACT DETAILS WHILST IN THE USAS CONTACT DETAILS
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EMERGENCY CONTACT DETAILS DO ANY OF THE FOLLOWING APPLY TO YOU?
A. Do you have a communicable disease; physical or mental disorder; or are you a drug abuser or addict? * Yes No
B. Have you ever been arrested or convicted for an ofense or crime that resulted in serious damage to property, or serious harm to another person or government authority; or ever violated any law related to possessing, using, or distributing illegal drugs? Yes No
C. Do you seek to engage or have you ever engaged in terrorist activities, espionage, sabotage or genocide? Yes No
D. 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? Or have you ever been excluded and deported; or been previously removed from the United States or procured or attempted to procure a visa or entry into the U.S. by fraud or misrepresentation?* Yes No
E. Have you ever been denied a U.S. visa or entry into the U.S. or had a U.S. visa cancelled on your current or previous passport? * Yes No
F. Have you ever stayed in the U.S. longer than the admission period granted to you by the U.S. government?* Yes No
* Waiver of Rights: I have read and understand that I hereby waive for the duration of my travel authorisation obtained via ESTA any rights to review or appeal of a U.S. Customs and Border Protection Ocer'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 identiers (including ngerprints and photographs) during processing upon arrival in the United States shall rearm my waiver of any rights to review or appeal of a U.S. Customs and Border Protection Ocer's determination as to my admissibility, or to contest, other than on the basis of an application for asylum, any removal action.
* 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.
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