US ESTA Application Form

Transcription

1 US ESTA Applicatin Frm The fllwing questins are mandatry and will enable us t cmplete yur applicatin fr a US ESTA. Please d nt leave any questins blank as this culd lead t a delay in Key Travel prcessing yur applicatin. Each member f yur travelling party must cmplete a separate applicatin. 1. Surname ( As shwn in yur passprt ) 2. Given Name (cmplete as in yur passprt) 3. Sex (please tick bx) Female Male Transgender 4. Are yu knwn by any ther name r aliases? (please prvide) Surname: Given Name: 5. Date f Birth Day: Mnth: Year: 6. City f Birth 7. Cuntry f Birth 8. Passprt Number 9. Cuntry f citizenship 10. Issue Date 11. Issuing Cuntry 12. Expiry Date (Please prvide) 13. Have yu ever been issued a passprt r natinal identity card fr travel by any ther cuntry? Issuing Cuntry Dcument Type? Dcument Number? Expiry Date?

2 (Please prvide) 14. Are yu nw, a citizen r natinal f any ther cuntry Cuntry f Citizenship / Natinality Hw did yu acquire citizenship / natinality frm this cuntry? Other 15. Are yu a member f the CBP Glbal Entry Prgram? ( Please prvide) PASSID / Membership Number* 16. Parents Full names. All applicants are required t fill ut this sectin. Father: Mther: Telephne number 17. Cntact Infrmatin Full Hme: Mbile: 18. Emplyment Infrmatin Jb Title Emplyer Name Full address Cntact number D yu have a current r previus emplyer? - Please g t questin 19, please cmplete 19. Is yur travel t the US ccurring in transit t anther cuntry Please g t questin Pint f cntact in the US Name: Full Cntact Number 21. Emergency Cntact infrmatin whilst in the US Name: Full Hme telephne number Mbile:

3 ELIGIBILITY QUESTIONS Required fields are indicated by a red asterisk *. 1) D yu have a physical r mental disrder; r are yu a drug abuser r addict; r d yu currently have any f the fllwing diseases (cmmunicable diseases are specified pursuant t sectin 361(b) f the Public Health Service Act):* Chlera Diphtheria Tuberculsis, infectius Plague Smallpx Yellw Fever Viral Hemrrhagic Fevers, including Ebla, Lassa, Marburg, Crimean-Cng Severe acute respiratry illnesses capable f transmissin t ther persns and likely t cause mrtality. 22. Have yu ever been arrested r cnvicted fr a crime that resulted in serius damage t prperty, r serius harm t anther persn r gvernment authrity?* 23. Have yu ever vilated any law related t pssessing, using, r distributing illegal drugs?* 24. D yu seek t engage in r have yu ever engaged in terrrist activities, espinage, sabtage, r gencide?* 25. Have yu ever cmmitted fraud r misrepresented yurself r thers t btain, r assist thers t btain, a visa r entry int the United States?* 26. Are yu currently seeking emplyment in the United States r were yu previusly emplyed in the United States withut prir permissin frm the U.S. gvernment?* 27. Have yu ever been denied a U.S. visa yu applied fr with yur current r previus passprt, r have yu ever been refused admissin t the United States r withdrawn yur applicatin fr admissin at a U.S. prt f entry?*

4 28. Have yu ever stayed in the United States lnger than the admissin perid granted t yu by the U.S. gvernment NO 29. Have yu traveled t, r been present in Iraq, Syria, Iran, Sudan, Libya, Smalia r Yemen n r after March 1, 2011?* List Cuntry Mnth and Year entered Mnth and Year f departure Reasn fr Travel With regard t immunity frm prsecutin, answer t this questin if all f the fllwing apply: (a) yu have cmmitted a serius criminal ffense in the United States as defined in 8 U.S.C. Sec. 1101(h), including any felny, at any time fr which immunity frm criminal jurisdictin was exercised; and (b) as a cnsequence f the ffense and exercise f immunity identified in (a), yu have departed frm the United States; and (c) yu have nt subsequently submitted fully t the jurisdictin f the curt in the United States having jurisdictin with respect t that ffense. Waiver f Rights: I have read and understand that I hereby waive fr the duratin f my travel authrizatin btained via ESTA any rights t review r appeal f a U.S. Custms and Brder Prtectin Officer's determinatin as t my admissibility, r t cntest, ther than n the basis f an applicatin fr asylum, any remval actin arising frm an applicatin fr admissin under the Visa Waiver Prgram. In additin t the abve waiver, as a cnditin f each admissin int the United States under the Visa Waiver Prgram, I agree that the submissin f bimetric identifiers (including fingerprints and phtgraphs) during prcessing upn arrival in the United States shall reaffirm my waiver f any rights t review r appeal f a U.S. Custms and Brder Prtectin Officer's determinatin as t my admissibility, r t cntest, ther than n the basis f an applicatin fr asylum, any remval actin arising frm an applicatin fr admissin under the Visa Waiver Prgram. Please read and tick t cnfirm Certificatin : I, the applicant, hereby certify that I have read, r have had read t me, all the questins and statements n this applicatin and understand all the questins and statements n this applicatin. The answers and infrmatin furnished in this applicatin are true and crrect t the best f my knwledge and belief The fee fr the USA ESTA is apprx 14 USD. This can vary in GBP depending n the current exchange rate but will be apprximately If yu wish t have yur applicatin prcessed n the pririty service please tick bx A pririty fee will be applied als if needed within 72 hurs f Key Travel receiving the .

5 If yur applicatin is nt urgent and yur nt travelling t the US within 72 hurs f yur applicatin being received by Key Travel, the applicatin will be prcessed within 5 wrking days. Please nte that nce the rder has been prcessed it is nt pssible t cancel r amend the request and full fee will need t be paid. Applicant Declaratin I wuld like t cnfirm the abve infrmatin is crrect. Name Signature: Date: