Form I-102 - Application For Replacement/initial Nonimmigrant Arrival-Departure Document
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1
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4Application for Replacement/Initial Nonimmigrant
Arrival-Departure Document
USCIS
Form I-102
Department of Homeland Security
OMB No. 1615-0079
U.S. Citizenship and Immigration Services
Expires 10/31/2019
Action Block
Receipt
To Be Completed by an
Attorney or Accredited
Representative,
if any.
For
Select this box if Form
USCIS
G-28 is attached to
New I-94 Number
Use
represent the applicant.
Only
Attorney State
License Number
Remarks
►
START HERE. Type or print in black ink
Part 1. Information About You
U.S. Physical Address
1.
Alien Registration Number (A-Number)
6.a.
In Care Of Name
►
A-
6.b.
Street Number
2.
USCIS Online Account Number (if any)
and Name
►
6.c. Apt.
Ste.
Flr.
Your Full Name
6.d.
City or Town
3.a. Family Name
(Last Name)
6.e.
State
6.f.
ZIP Code
3.b.
Given Name
(First Name)
Other Information
3.c.
Middle Name
►
7.
Date of Birth
(mm/dd/yyyy)
U.S. Mailing Address
8.
Country of Birth
4.a.
In Care Of Name
9.
Country of Citizenship
4.b.
Street Number
and Name
10.
U.S. Social Security Number (if any)
4.c. Apt.
Ste.
Flr.
►
4.d.
City or Town
Entry Information
4.e.
4.f.
State
ZIP Code
11.
Date of Last Entry into the United States
5.
Is your current U.S. mailing address the same as your
►
(mm/dd/yyyy)
U.S. physical address?
Yes
No
12.
Place of Last Entry into the United States (City and State)
If you answered "No" to Item Number 5., provide your
U.S. physical address in Item Numbers 6.a. - 6.f.
Form I-102 10/19/17 N
Page 1 of 4
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