Form I-192 04/09/19 Page 1 of 11 START HERE - Type or print in black ink. Attorney State Bar Number (if applicable) Select this box if Form G-28 or Form G-28I is attached.Volag Number (if any) To be completed by an attorney or accredited representative (if any). Attorney or Accredited Representative USCIS Online Account Number (if any)Application for Advance Permission to Enter as a Nonimmigrant Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form I-192 OMB No. 1615-0017 Expires 04/30/2021I am applying to the Secretary of Homeland Security for permission to enter the United States temporarily under the provisions of the Immigration and Nationality Act (INA) section 212(d)(3)(A)(ii), section 212(d)(13), or section 212(d)(14).I am seeking this permission so that I may obtain (select only one box): Admission as a nonimmigrant (other than as a T or U nonimmigrant). Status as a victim of trafficking (T nonimmigrant status) or a victim of a crime (U nonimmigrant status).1.2. Part 1. Application Type Part 2. Information About You Your Full Name 1.a.1.b.1.c.Family Name (Last Name) Given Name (First Name)Middle Name Received Returned Trans. Out Trans. In Completed Fee Stamp Action by the Department of Homeland SecurityT Nonimmigrant/Waiver under INA 212(d)(13) and 8 CFR 212.16 U Nonimmigrant/Advance Permission under INA 212(d)(3)(A) and 8 CFR 212.17 U Nonimmigrant/Waiver under INA 212(d)(14) and 8 CFR 212.17 Granted, subject to revocation at any time, upon the following terms and conditions Nonimmigrant other than T or U nonimmigrant/Advance Permission under INA 212(d)(3)(A) and 8 CFR 212.4 INA 212(a)(6) T Nonimmigrant/Advance Permission under INA 212(d)(3) and 8 CFR 212.16 INA 212(a)(2) INA 212(a)(1) Action Stamp Benefits Category:INA 212(a)(3) INA 212(a)(10) INA 212(a)(4) Other: Ground of Inadmissibility Date of Action (mm/dd/yyyy) DD or OIC Office INA 212(a)(9) For DHS Use Only INA 212(a)(8) INA 212(a)(9) American LegalNet, Inc. www.FormsWorkFlow.com Form I-192 04/09/19 Page 2 of 11 3.c.Middle Name3.b.Given Name (First Name)3.a.Family Name (Last Name) Alien Registration Number (A-Number) (if any)USCIS Online Account Number (if any)Date of Birth (mm/dd/yyyy)A-4.5.6. Other Information Part 2. Information About You (continued)8.a.8.b.8.c.Place of BirthCity or TownState or ProvinceCountry Country of Citizenship or Nationality9. 7. FemaleGender Male Safe Mailing AddressIf you are a T or U visa applicant, and do not want U.S. Citizenship and Immigration Services (USCIS) to send notices about this application to your home, you may provide a safe mailing address.11.a.In Care Of Name (if any) Organization Name (if applicable) 11.b.11.c.11.d.11.e.11.f.11.h.11.j.11.i.City or TownProvinceCountry Postal Code ZIP Code11.g.StateStreet Number and Name Apt. Ste. Flr. Mailing Address10.b.10.c.10.d.10.e.10.g.10.i.10.h.10.a.City or TownProvinceCountry Postal Code ZIP Code10.f.StateStreet Number and Name Apt. Ste. Flr. In Care Of Name (if any) Provide all other names you have ever used, including aliases, maiden name, and nicknames. If you need extra space to complete this section, use the space provided in Part 8. Additional Information. Other Names Used (if any)Family Name (Last Name) 2.a.Given Name (First Name)2.b.Middle Name2.c. (USPS ZIP Code Lookup) American LegalNet, Inc. www.FormsWorkFlow.com Form I-192 04/09/19 Page 3 of 11 Part 2. Information About You (continued)Physical Address 2 14.a.14.b.14.c.14.d.14.f.14.h.14.g.City or TownProvinceCountry Postal Code ZIP Code14.e.StateStreet Number and Name Apt. Ste. Flr. Dates of ResidenceFrom (mm/dd/yyyy)15.b. To (mm/dd/yyyy) 15.a. 18.h.18.g.Country Postal Code Dates of ResidenceFrom (mm/dd/yyyy)19.b. To (mm/dd/yyyy) 19.a.18.c.18.d.18.f.City or TownProvinceZIP Code18.e.State Physical Address 4 18.a.18.b.Street Number and Name Apt. Ste. Flr. Physical Address 3 16.a.16.b.16.c.16.d.16.f.16.h.16.g.City or TownProvinceCountry Postal Code ZIP Code16.e.StateStreet Number and Name Apt. Ste. Flr. Dates of ResidenceFrom (mm/dd/yyyy)17.b. To (mm/dd/yyyy) 17.a. Address HistoryProvide physical addresses for everywhere you have lived during the last five years, whether inside or outside the United States. Provide your current address first. If you need extra space to complete this section, use the space provided in Part 8. Additional Information.Physical Address 1 (current address)12.a.12.b.12.c.12.d.12.f.12.h.12.g.City or TownProvinceCountry Postal Code ZIP Code12.e.StateStreet Number and Name Apt. Ste. Flr. Dates of ResidenceFrom (mm/dd/yyyy)13.b. To (mm/dd/yyyy) 13.a. American LegalNet, Inc. www.FormsWorkFlow.com Form I-192 04/09/19 Page 4 of 11 Part 2. Information About You (continued) Immigration and Criminal History26.Have you previously filed an application for advance permission to enter the United States as a nonimmigrant?Do you believe that you may be inadmissible to the United States?If you answered "Yes" to Item Number 26., explain the reasons why you believe, according to the best of your knowledge, that you may be inadmissible in Part 8. Additional Information. If you were told that you are inadmissible, provide the reason you were given.If you answered "Yes" to Item Number 27., provide the details in Item Numbers 28. - 29.e. If you need extra space to complete this section, use the space provided in Part 8. Additional Information. Yes No Yes No27.If you (or somebody else on your behalf) have filed multiple applications or petitions for immigration benefits with the U.S. Government, use the space provided in Part 8. Additional Information to provide the answers to Item Numbers 32.a. - 32.c. for each of your additional applications or petitions. 32.a.Location Where You (or the Other Person) Filed the Application or Petition (for example, USCIS office or Port-of-Entry);Outcome of the Application or Petition (for example, approved, denied, or is pending).Type of Application or Petition Filed32.b.32.c. 28.Date Application Filed (mm/dd/yyyy) USCIS Office or U.S. Port-of-EntryLocation where you filed your application (for example, USCIS Office or Port-of-Entry).29.b.State or Province29.d.Receipt Number (if available)29.e.Country29.c.City or Town 29.a. 30.Have you EVER been in the United States for a period of six months or more?If you answered "Yes" to Item Number 30., provide the dates you were in the United States (from and to) and your immigration status at the time of entry into the United States in the space provided in Part 8. Additional Information. Yes No31.Have you EVER filed an application or petition for immigration benefits with the U.S. Government, or has one ever been filed on your behalf? Yes NoIf you answered "Yes" to Item Number 31., provide the information requested in Item Numbers 32.a. - 32.c. Travel Information20.a.20.b.Location at Which you Plan to Enter the United States (desired Port-of-Entry)City State 21.Name of Port-of-Entry How do you plan to travel to the United States? (For example, by plane, ship, car) When do you plan to enter the United States? (mm/dd/yyyy) 23.24.Approximate Length of Stay in the United States NOTE: If you are applying for T or U nonimmigrant status and are in the United States, you may skip Item Numbers 20. - 25.25.What is the purpose of your stay in the United States? Explain fully below. 22. American LegalNet, Inc. www.FormsWorkFlow.com Form I-192 04/09/19 Page 5 of 11 Black Gray Green Maroon Pink Hazel Brown Blue Eye Color (Select only one box)5. Unknown/OtherHair Color (Select only one box) Black Brown Red White Unknown/OtherSandyGrayBlondBald (No hair) 6. Part 4. Other Information About You Employment HistoryProvide your employment history for the last five years, whether inside or outside the United States. Provide the most recent employment first. If you need extra space to complete this section, use the space provided in Part 8. Additional Information.Employer 1 (current or most recent) Address of Employer or Company Name of Employer or Company1.2.a.2.b.2.c.2.d.2.f.2.h.2.g.City or TownProvinceCountry Postal Code ZIP Code2.e.StateStreet Number and Name Apt. Ste. Flr. From (mm/dd/yyyy) To (mm/dd/yyyy) Dates of Employment4.a.4.b. Yo