Application
Verification
File Number
Payment
Applicant Information
Family Name *
    • Enter your family name as the family name appears on your passport under the Family Name or Surname field. The family name is required to complete the application.
First (Given) Name *
    • 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. First name is required to complete the application. If you have no first name, then enter the letters FNU which stands for First Name Unknown.
Are you known by any other names or aliases?*
    • Indicate whether you are known by any other names or aliases by selecting yes or no. Answering this question is required to complete your application.
      Yes       No
Other Names/Aliases*
    • Enter up to 10 other names or aliases by which you are known if you selected "yes" to the previous question. At least one entry is required to complete the application. For each alias: In the Family Name field, enter your alternate family name. The family name is required to complete the application. In the First (Given) Name field, enter your alternate first (given) name. Do not include the middle name in this field. The first name is required to complete the application. If you have no alternate first name, then enter the letters FNU which stands for First Name Unknown.
Country of Citizenship *
    • Choose the country of citizenship, as it appears on your passport. The passport issuing country is required to complete the application.
City of Birth*
    • Enter the city, town, village, or hamlet in which you were born. The city, town, village, or hamlet where you were born is required to complete the application. If you do not know the city in which you were born, enter UNKNOWN.
Country of birth *
    • Choose the country in which you were born. The country where you were born is required to complete the application.
Residential country *
    • Choose the country in which you reside. The country where you live is required to complete the application.
Are you a citizen of any other country?*
    • Indicate whether you are a citizen of any other country. Answering this question is required to complete your application.
      Yes       No
Other Citizenship*
    • In the Country field, choose the country of your other citizenship(s). If you answered yes above, the country is required to complete your application. In the Passport Number field, enter your passport number as it appears in your other passport(s). The passport number may contain numbers and/or characters. Please closely distinguish between the two, such as the numbers zero and one, and the letters O and I. The passport number is optional to complete your application.
Country

Passport Number
Parents*
    • Enter the names of your parents. These are required to complete the application. 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. The family name is required to complete the application. 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. The first name is required to complete the application. If your parent has no first name, or if you do not know one or both of your parents, enter UNKNOWN.
Birth Date
Day *
    • Choose the day on which you were born. The day of birth is required to complete the application or to check the status of your application.
Month *
    • Choose the month in which you were born. The month of birth is required to complete the application or to check the status of your application.
Year *
    • Choose the year in which you were born. The year of birth is required to complete the application or to check the status of your application.
Sex *
    • Choose your gender, either male or female. The sex (gender) is required to complete the application.
      Male       Female
E-Mail Address *
    • Enter the e-mail address at which you can be contacted. The e-mail address is optional to complete the application.
Home Address
Address line 1*
    • 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. Address line 1 is required to complete the application.
Address Line 2
City*
    • In the City field, enter the city, town, village, or hamlet. The city, town, village, or hamlet is required to complete the application.
Country*
    • In the Country field, choose the country. The country is required to complete the application.
Telephone Number
Phone type*
    • Phone type
Country Code *
    • Choose the country code of the telephone number where you can be contacted. The country code and telephone number are optional to complete the application.
Number *
    • Enter the telephone number where you may be contacted. The telephone number is optional to complete the application.
Passport Information
Passport Number *
    • 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. The passport number is required to complete the application or to check the status of your application.
Passport Issuing Country (Country of Citizenship) *
    • Choose the country of citizenship, as it appears on your passport. The passport issuing country is required to complete the application.
Passport Issuance Date
Day *
    • Choose the day on which your passport was issued, as it appears on your passport under the Date of Issue field. The day on which the passport was issued is required to complete the application.
Month *
    • Choose the month in which your passport was issued, as it appears on your passport under the Date of Issue field. The month in which the passport was issued is required to complete the application.
Year *
    • Choose the year in which your passport was issued, as it appears on your passport under the Date of Issue field. The year in which the passport was issued is required to complete the application.
Passport Expiration Date
Day *
    • Choose the day on which your passport expires, as it appears on your passport under the Expiration Date or Extension field. The day on which the passport expires is required to complete the application.
Month *
    • Choose the month in which your passport expires, as it appears on your passport under the Expiration Date or Extension field. The month in which the passport expires is required to complete the application.
Year *
    • Choose the year in which your passport expires, as it appears on your passport under the Expiration Date or Extension field. The year in which the passport expires is required to complete the application.
Travel Information
City Where You are Boarding
    • Enter the last city where you will board an aircraft prior to arriving in the United States on this trip. The city where the applicant will board is optional to complete the application.
Flight or Ferry Information
Carrier Name
    • Choose the carrier name for the carrier on which you will be traveling to the United States, if your travel information is available. The carrier name is optional to complete the application.
Flight Number or Ferry Name
    • Enter the flight number or vessel name for the carrier on which you will be traveling to the United States, if your travel information is available. The flight number or vessel name is optional to complete the application.
Address While In The United States
Address Line 1
    • Enter the number and street of the location where you will stay while in the United States. Do not include the city and state in this field. The address is optional to complete the application. • If multiple locations are planned, enter the first address. • If the complete address is not known, enter the name of the hotel or location you will visit. You may update this information once confirmed. • If you are leaving the United States immediately and do not have an address, enter the words ”In Transit” and your final destination location.
Address Line 2
    • Enter apartment, suite, unit, floor, building, or other, if appropriate. Do not include the city and state in this field. Address line 2 is optional to complete the application.
City
    • Enter the city of the address where you will stay while in the United States. The city is optional to complete the application.
State
    • Enter the state of the address where you will stay while in the United States. The state is optional to complete the application.
Emergency Contact Information In or Out of the United States
Family Name *
    • 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. You must complete this field to complete the application. If you have no emergency contact, enter UNKNOWN.
First (Given) Name *
    • 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 First (Given) Name field, enter the emergency contact’s first name. You must complete this field to complete the application. If you have no emergency contact (or your contact has only one name), enter UNKNOWN.
E-Mail Address *
    • Enter your emergency contact's e-mail address. E-mail address is required to complete the application. You may also enter UNKNOWN.
Telephone Number
Country Code *
    • In the Country Code field, enter the country code of your emergency contact's telephone number. The country code is required to complete the application. If you do not have an emergency contact telephone country code you may enter zeros.
Number *
    • In the Number field, enter your emergency contact's telephone number. The number is required to complete the application. If you do not have an emergency contact telephone number you may enter zeros.
GE MEMBERSHIP
Global Entry is a program developed by US Customs and Border Protection to speed up the process of entry into the United States for low-risk, controlled international passengers prior. Upon arrival in the United States, program members move directly to the Global Entry Auto Binder, enabling them to bypass passport checkpoints and customs clearance papers.
Are you a member of the CBP Global Entry Program?*
    • Are you a member of the CBP Global Entry Program?
Yes      No
PASSID number / Membership number*
    • PASSID number / Membership number
SOCIAL MEDIA (OPTIONAL)
Social networks provider / Platform*
    • Social networks provider / Platform
Social Media ID*
    • Social Media ID
Travel Information
Is your travel to the US occurring in transit to another country? *
    • Indicate whether your travel to the US is occurring in transit to another country by selecting yes or no. Answering this question is required to complete your application.
Yes      No
US Point of Contact Information
US Point of Contact*
    • A U.S. point of contact may be a friend, relative, or business associate. If you do not have a U.S. 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.
Address line 1*
Address Line 2
City*
Telephone Number*
Employment Information
Do you have a current or previous employer?*
    • Indicate whether you have a current or previous employer by selecting yes or no. Answering this question is required to complete your application.
Yes      No
Employer Name*
    • Enter the name of your current employer. If you are not currently employed, enter the name of your previous employer. Employer name is required to complete the application. You may also enter SELF-EMPLOYED, STUDENT, CHILD, HOMEMAKER, STAY-AT-HOME PARENT, or any other word to describe your employment status.
Job Title
    • Enter the job title of your current or previous employment. Job title is optional to complete this application.
Telephone Number
Address
Address line 1*
Address Line 2
City*
Country*
Do any of the following apply to you? (Answer Yes or No)

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 been arrested or convicted of an offense that caused serious material damage or serious harm to another person or governmental authority*
    • 2) Have you been arrested or convicted of an offense that caused serious material damage or serious harm to another person or governmental authority
Yes      No

3) Have you ever violated any law related to possessing, using, or distributing illegal drugs?

*

    • 3) Have you ever violated any law related to possessing, using, or distributing illegal drugs?

Yes      No
4) Do you intend to participate or have you participated in terrorist activities, espionage, sabotage or genocide?*
    • 4) Do you intend to participate or have you participated 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? United ?*
Yes      No
6) Cherchez-vous à présent un emploi aux États-Unis ou avez-vous travaillé dans le passé aux États-Unis sans avoir obtenu une permission préalable du gouvernement américain ?*
    • 6) Cherchez-vous à présent un emploi aux États-Unis ou avez-vous travaillé dans le passé aux États-Unis sans avoir obtenu une permission préalable du gouvernement américain ?
Yes      No
7) Have you ever been refused a US visa that you applied for with your current passport or old passport, or have you ever been refused entry to the United States or removed your right to admission to a US entry point?*
    • 7) Have you ever been refused a US visa that you applied for with your current passport or old passport, or have you ever been refused entry to the United States or removed your right to admission to a US entry point?
Yes      No
If yes: when*
    • If yes: when
or*
    • or
8) Have you ever stayed in the United States longer than the US government's admission period?*
    • 8) Have you ever stayed in the United States longer than the US government's admission period?
Yes      No
9) Did you travel to Iraq, Syria, Iran, Sudan, Libya, North Korea, Somalia or Yemen on or after March 1, 2011?*
    • 9) Did you travel to Iraq, Syria, Iran, Sudan, Libya, North Korea, Somalia or Yemen on or after March 1, 2011?
Yes      No
Waiver of Rights: I have read and understand that I hereby waive for the duration of my travel authorization obtained via ESTA any rights to review or appeal of a U.S. Customs and Border Protection Officer's determination as to my admissibility, or to contest, other than on the basis of an application for asylum, any removal action arising from an application for admission under the Visa Waiver Program.

In addition to the above waiver, as a condition of each admission into the United States under the Visa Waiver Program, I agree that the submission of biometric identifiers (including fingerprints and photographs) during processing upon arrival in the United States shall reaffirm my waiver of any rights to review or appeal of a U.S. Customs and Border Protection Officer's determination as to my admissibility, or to contest, other than on the basis of an application for asylum, any removal action arising from an application for admission under the Visa Waiver Program.
*  Certification: I, the applicant, hereby certify that I have read, or have had read to me, all the questions and statements on this application and understand all the questions and statements on this application. The answers and information furnished in this application are true and correct to the best of my knowledge and belief.
For third-parties submitting the application on behalf of the applicant, I hereby certify that I have read to the individual whose name appears on this application (applicant) all the questions and statements on this application. I further certify that the applicant certifies that he or she has read, or has had read to him or her, all the questions and statements on this application, understands all the questions and statements on this application, and waives any rights to review or appeal of a U.S. Customs and Border Protection Officer's determination as to his or her admissibility, or to contest, other than on the basis of an application for asylum, any removal action arising from an application for admission under the Visa Waiver Program.

The answers and information furnished in this application are true and correct to the best of the applicant's knowledge and belief.
*  I accept the terms and conditions and have been informed that the site www.electronicesta.com is not affiliated with the U.S. government authorities or government website cbp.gov. The price is 59euros and covers the cost of protection of U.S. borders 14USD. I can get this form to 14USD on the official website of the U.S. Embassy, but in this case I can not benefit from your help and support.
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