1) Do you have a physical or mental disorder; or are you a drug abuser or addict; or do you currently have any of the following diseases (communicable diseases are specified pursuant to section 361(b) of the Public Health Service Act):Cholera, Diphtheria, Tuberculosis, infectious, Plague, Smallpox, Yellow Fever, Viral Hemorrhagic Fevers, including Ebola, Lassa, Marburg, Crimean-Congo, Severe acute respiratory illnesses capable of transmission to other persons and likely to cause mortality.*
Yes
No
2) 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?*
Yes
No
3) Have you ever violated any law related to possessing, using, or distributing illegal drugs?*
Yes
No
4) Do you seek to engage in or have you ever engaged in terrorist activities, espionage, sabotage, or genocide?*
Yes
No
5) Have you ever committed fraud or misrepresented yourself or others to obtain, or assist others to obtain, a visa or entry into the United States?*
Yes
No
6) 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?*
Yes
No
7) Have you ever been denied a U.S. visa you applied for with your current or previous passport, or have you ever been refused admission to the United States or withdrawn your application for admission at a U.S. port of entry?*
Yes
No
8) Have you ever stayed in the United States longer than the admission period granted to you by the U.S. government?*
Yes
No
9) Have you traveled to, or been present in Iraq, Syria, Iran, Sudan, Libya, Somalia or Yemen on or after March 1, 2011?*
Yes
No
Country
IRAN (IRN)
IRAQ (IRQ)
LIBYA (LBY)
SOMALIA (SOM)
SUDAN (SDN)
SYRIA (SYR)
YEMEN (YEM)
From
Month
January February March April May June July August September October November December
Year
2019 2018 2017 2016 2015 2014 2013 2012 2011
To
Month
January February March April May June July August September October November December
Year
2019 2018 2017 2016 2015 2014 2013 2012 2011
Primary Reason
To travel as a tourist (vacation)
For personal travel or a family visit (including emergencies).
For commercial / business purposes.
To carry out official duties as a full-time employee of the government of a Visa Waiver Program country.
To perform military service in the armed forces of a Visa Waiver Program country.
To conduct work as a journalist.
To engage in humanitarian assistance on behalf of a humanitarian or international non-governmental organization.
To carry out official duties on behalf of an international organization or regional (multilateral or inter-governmental) organization.
To carry out official duties on behalf of a sub-national government or body of a VWP country
To attend an academic institution.
To participate in a professional exchange or conference
To participate in a cultural exchange program.
Other
Disclaimer: Yes, I have read and understand the information and agree to these terms.
The Electronic System for Travel Authorization performs checks against law enforcement databases. All travelers seeking admission to the United States under the Visa Waiver Program are required to obtain an electronic travel authorization using this system prior to being granted boarding.
If your electronic travel authorization application is approved, it establishes that you are eligible to travel, but does not establish that you are admissible to the United States under the Visa Waiver Program. Upon arrival to the United States, you will be inspected by a U.S. Customs and Border Protection Officer at a port of entry who may determine that you are inadmissible under the Visa Waiver Program or for any reason under United States law.
A determination that you are not eligible for electronic travel authorization does not preclude you from applying for a visa to travel to the United States.
All information provided by you, or on your behalf by a designated third party, must be true and correct. An electronic travel authorization may be revoked at any time and for any reason, such as new information influencing eligibility. You may be subject to administrative or criminal penalties if you knowingly and willfully make a materially false, fictitious, or fraudulent statement or representation in an electronic travel authorization application submitted by you or on your behalf.
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