DEPARTMENT OF HOMELAND SECURITY
U.S.CustomsandBorderProtection
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Record - Instructions
I-94 ArrivaUDeparture
This form must be completedby all personsexcept U.S. Citizens,returning resident
aliens.alienswith immilrant visas,arid Canadianeitizens visiting or in traniit.
Type or print legibly with pen in ALL CAPITAL LETTERS. Use English. Do not
w-rireon the back-of ihis fonir.
This form is in two parts. Pleasecomplete both the Arrival Record (Items I through
l3) and the Departure Record (Items l4 through l7).
When all items are completed, present this form to the CBP Officer.
Itern 7 - If you are entering the Uni0ed States by land, enter LAND in this space.
If you are entering the United Statesby ship, enter SEA in this space.
CBPFormI-94 (10/04)
Admission Number
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SAMPLE
IMMIHELP.COM
Arrival Record
l. Family Name
First (Given) Name
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.r Birth Date (Day/Mo/Yr)
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-t. CountryofCitizenship
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().PassportNumber
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5 Sex (Male or Female)
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lTAirlineandFlightNumber
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.t Citf Where You Boarded
8. Country Where You Live
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10.City WhereVisaWasIssued
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I L Date Issued (DaylMo/Yr)
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Address While in the United States (Number and Street)
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l . l City and State
CBPFormI-94 (10/04)
Departure Number
OMB No. l65l-01| I
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DepartureRecord
| 6. Birth Date (Dayfivlo/Yr)
CBPFormI-94 ( l0/04)
SeeOther Side
STAPLEHERE
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Primary Inspection
Applicant's
Name
Date
Referrcd
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Time -
Insp.#
ReasonReferred
l t r p p E v i s a E p a r o l e E s r . sE r w o v
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SecondaryInspection
End Secondary
Time
Insp.#
Disposition
26. Itinerary/Comments
SAMPLE
IMMIHELP.COM
27. TWOV TicketNumber
\larrrirrg - A nonimmigrantwho acceptsunauthorizedemploymentis subjectto
deportation.
Important - Retainthis permit in your possesioniyoa mustsanender it when you
leavethe U.S. Failure to do so may delayyour entry into the U.S. inthe future.
You are.auftonizedto stay in the U,S. only until the dae wrifien on this form. To
rernain past ttris date, without permissionfrom Departrnentof Homeland Security
authorities,is a violationof thelaw.
Surrenderthis pernritwhen1.ou lcavcthc U.S.:
- By seaor air, to the transportationline;
- AcrosstheCanadianborcler.to a CanadianOfficial:
- AcrosstheMexicanborder,'toa U.S.Official.
Studentsplanningto reenterthe U.S. within 30 davsto retum to the sameschool.
- see
"Anival-Departure" on pag€2 of Form I-20 priorlo surrendering this permit.
Record of Changes
Port:
Date:
Carier:
Flight #/Ship Name:
Ileparture Record