I-192, Application for Advance Permission to Enter as Nonimmigrant (United States)
This form is to apply for permission to return to unrelinquished domicile in the United States. The form provided here is simply a sample of what the actual Form I-192 looks like.
Department of Homeland Security
U.S. Citizenship and Immigration Services
I-192, Application for Advance Permission to Enter as Nonimmigrant
[Pursuant to Section 212(d)(3) of the INA]
Fee Stamp
File No. A-_______________________________
Date _______________________________
1. I hereby apply to the Secretary of Homeland Security for permission to enter the United States temporarily under the provisions of section 212(d)(3) of the Immigration and Nationality Act (INA).
1. Full Name (Print) _______________________________
2. Date of Birth (mm/dd/yyyy) _______________________________
3. Place of Birth (City-Town, State/Province, Country) _______________________________
4. Present Citizenship/Nationality _______________________________
5. Present Address _______________________________
6. All Addresses at which I have resided during the past five years. (Use separate sheet of paper, if necessary) _______________________________
7. Desired Port of Entry into the United States _______________________________
8. Means of Transportation _______________________________
9. Proposed Date of Entry _______________________________
10. Approximate Length of Stay in the United States. _______________________________
11. My purpose for entering the United States is: (Explain fully)_______________________________
12. I believe I may be inadmissible to the United States for the following reasons and no others:_______________________________
13. I ____ have ____ have not previously filed an application for advance permission to enter as a nonimmigrant
on ___________________, __________, at ________________________
14. I understand that the information herein contained may be used in any proceedings (including civil or criminal judicial proceedings, or deportation or removal proceedings) hereafter instituted against me.
I certify that the statements above and all attachments hereto are true and correct to the best of my knowledge and belief.
_______________________________ (Signature of Applicant)
________________________________ (Date)
15. Signature of person preparing form, if other than applicant.
I declare that this document was prepared by me at the request of the applicant and is based on all information of which I have any knowledge.
_______________________________ (Signature)
_______________________________ (Address)
_______________________________ (Date)
Action by the Department of Homeland Security
____ Granted, subject to revocation at any time, upon the following terms and conditions:
_______________________________
Date of Action _______________________________
DD or OIC Office _______________________________