ESTA Application Form for Australian and New Zealand Citizens

PLEASE FILL OUT THE FOLLOWING TRAVEL AUTHORIZATION INFORMATION:

Choose your gender, either male or female.

Gender *

Female Male

Enter your first (given) name as the first name appears on your passport under the First or Given Name field. Do not include the middle name in this field. If you have no first name, then enter the letters FNU which stands for First Name UNKNOWN.

First Name *

Enter your family name as the family name appears on your passport under the Family Name or Surname field.

Last Name *

Indicate whether you are known by any other names or aliases by selecting yes or no.

Are you known by any other names or aliases? *

No Yes

Select the day, month and year you were born.

Birthdate *

Choose the country of birth, as it appears on your passport.

Country of Birth *

Enter the city, town, village, or hamlet in which you were born. If you do not know the city in which you were born, enter UNKNOWN.

City of Birth *

Enter the names of your parents. If you do not know the name of one or both of your parents, enter UNKNOWN, for each parent. This field can include the names of your biological, adoptive, step-parent or guardian. In the Family Name field, enter your parent's family name. If you do not know one or both of your parents, enter UNKNOWN. In the First (Given) Name field, enter your parent's first (given) name. Do not include the middle name in this field. If your parent has no first name, or if you do not know one or both of your parents, enter UNKNOWN.

Parents Names

Last Name *

First Name *

Last Name *

First Name *

Contact information

Enter the telephone number where you may be contacted. If you do not have a telephone number, you may provide an alternative third-party telephone number belonging to a point of contact (e.g. a family member, friend, or business associate). In the Type field, choose the type of the telephone number where you may be contacted. In the Country Code field, enter the country code of the telephone number where you may be contacted.

Telephone Number *

Type *

Country Code *

Number *

Enter the e-mail address at which you can be contacted. The e-mail address is mandatory to complete the application. Please provide a working e-mail address.

E-mail *

Please confirm the e-mail address at which you can be contacted.

Confirm your E-mail *

In the Address Line 1 field, enter the number and street of the location of your home address. Do not include the city and state in this field. In the House or Apartment number field, enter apartment, suite, unit, or other, as appropriate. Do not include the city and state in this field. In the Address Line 2 field, enter floor, building, or other, as appropriate. Do not include the city and state in this field. In the City field, enter the city, town, village, or hamlet. In the State/Province/Region field, enter the state, province, or region. In the Country field, choose the country.

Home Address

Address Line 1 *

Address Line 2

House or Apartment number

City *

State / Province / Region *

Country *

Emergency contact information in the US or Abroad

Enter your emergency point of contact who may be a person in or outside of the United States, e.g., a family member, friend, or business associate. In the Family Name field, enter your emergency contact’s family name. If you have no emergency contact, enter UNKNOWN. In the First (Given) Name field, enter the emergency contact’s first name. If you have no emergency contact (or your contact has only one name), enter UNKNOWN.

Emergency Contact *

First Name *

Last Name *

In the Country Code field, enter the country code of your emergency contact's telephone number. If you do not have an emergency contact telephone country code you may enter zeros. In the Number field, enter your emergency contact's telephone number. If you do not have an emergency contact telephone number you may enter zeros.

Telephone Number *

Country Code *

Number *

Enter your emergency contact's e-mail address. You may also enter UNKNOWN.

E-mail *

Travel information

Indicate whether your travel to the US is occurring in transit to another country by selecting yes or no.

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

No Yes

A US point of contact may be a friend, relative, or business associate. If you do not have a US point of contact, please enter the name, address and telephone number of the location where you will be staying (e.g. a hotel name). You may also enter UNKNOWN.

Contact information in the USA

Contact Point in the US *

In the Address Line 1 field, enter the number and street of your US point of contact's address. Do not include the city and state in this field. You may also enter UNKNOWN. In the House or Apartment number field, enter apartment, suite, unit, or other, as appropriate. Do not include the city and state in this field. In the Address Line 2 field, enter floor, building, or other, as appropriate. Do not include the city and state in this field. In the City field, enter the city. You may also enter UNKNOWN. In the State field, choose the state. You may also select UNKNOWN.

Address Line 1 *

Address Line 2

House or Apartment number

City *

State / Province / Region *

Enter your US point of contact's telephone number. If you do not have a point of contact telephone number you may enter zeros.

Telephone Number *

Occupational information

Indicate whether you have a current or previous employer by selecting yes or no.

Do you presently or in the past work for a corporation / business? *

No Yes

Enter the name of your current employer. If you are not currently employed, enter the name of your previous employer. You may also enter SELF-EMPLOYED, STUDENT, CHILD, HOMEMAKER, STAY-AT-HOME PARENT, or any other word to describe your employment status.

Occupational information

Name of Employer *

In the Address Line 1 field, enter the number and street of the location of the employer you listed. Do not include the city and state in this field. If you do not know the address of the employer you listed you may enter UNKNOWN. In the Address Line 2 field, enter floor, building, or other, as appropriate. Do not include the city and state in this field. In the City field, enter the city, town, village, or hamlet. If you do not know the city you may enter UNKNOWN. In the State/Province/Region field, enter the state, province, or region. If you do not know the state/province/region you may enter UNKNOWN. In the Country field, choose the country. You may also select UNKNOWN.

Address Line 1 *

Address Line 2

House or Apartment number

City *

State / Province / Region *

Country *

In the Country Code field, enter the country code of your employer's telephone number. In the Number field, enter your employer's telephone number.

Country Code

Number

Enter the job title of your current or previous employment.

Job Title

Please answer with Yes or No to the following questions

Do you have a communicable disease; physical or mental disorder; or are you a drug abuser or addict?

No Yes

Communicable Diseases

Under United States law, communicable diseases of public health significance include:

Chancroid
Gonorrhea
Granuloma inguinale
Leprosy, infectious
Lymphogranuloma venereum
Syphilis, infectious stage
Tuberculosis, active

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 USA?

No Yes

Are you currently seeking employment in the United States or where you previously employed in the USA without prior permission from the US government?

No Yes

Have you ever been refused a US visa or entry or had a visa revoked? If yes, please elaborate when and where?

No Yes

Have you ever stayed in the United States longer than the admission period granted to you by the US government?

No Yes

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

No Yes

PLEASE FILL OUT THE FOLLOWING TRAVEL AUTHORIZATION INFORMATION:

Passport information

OTHER CITIZENSHIP/NATIONALITY

Contact information

Emergency contact information in the US or Abroad

Travel information

Occupational information

Please answer with Yes or No to the following questions

Communicable Diseases