PLEASE FILL OUT THE FOLLOWING TRAVEL AUTHORIZATION INFORMATION:

Choose your gender, either male or female.
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.
Enter your family name as the family name appears on your passport under the Family Name or Surname field.
Indicate whether you are known by any other names or aliases by selecting yes or no.
Enter up to 10 other names or aliases by which you are known if you selected 'yes' to the previous question. For each alias: In the Family Name field, enter your alternate family name. In the First (Given) Name field, enter your alternate first (given) name. Do not include the middle name in this field. If you have no alternate first name, then enter the letters FNU which stands for First Name Unknown.
Select the day, month and year you were born.
Choose the country of birth, as it appears on your passport.
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.
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.

Passport information

Enter your passport number as it appears on your passport. The passport number may contain numbers and/or characters.Please closely distinguish between the number zero and the letter O.
Choose the day, month and year on which your passport was issued, as it appears on your passport under the Date of Issue field.
Choose the day, month and year on which your passport expires, as it appears on your passport under the Expiration Date or Extension field.
Choose the country of citizenship, as it appears on your passport.
If you have never been issued any one of these documents by any other country answer "No" to this question. If you have been issued one of these documents from another country, but you do not remember the passport number or national identification card number and the year of expiration answer "UNKNOWN" in the passport number field.

OTHER CITIZENSHIP/NATIONALITY

If Yes, select the country first, then select how you acquired the citizenship/nationality.
"Previous" means at any time in the past, without limitation.

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

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

Travel information

Indicate whether your travel to the US is occurring in transit to another country by selecting yes or no.
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.
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.
Enter your US point of contact's telephone number. If you do not have a point of contact telephone number you may enter zeros.

Occupational information

Indicate whether you have a current or previous employer by selecting yes or no.
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.
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.
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.
Enter the job title of your current or previous employment.

Please answer with Yes or No to the following questions

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