Below you can preview all the questions of the module is, the mandatory authorization for those who want to travel to the United States without the need for a visa. Updated in August 2015.
The asterisk indicates the mandatory answers.
Information about the applicant
Last Name *
Full Name *
Are you known by other names or aliases? *
Date of birth * (Day, Month, Year)
City of Birth*
Country of birth*
Parents * (insert the names of the parents, if they are unknown write "UNKNOWN")
Passport number *
Passport issuing country *
Passport Issue Date * (Day, Month, Year)
Passport expiration date * (Day, Month, Year)
Country of Citizenship*
Are you a citizen of another country? * (Indicate YES if you have another citizenship in addition to the one declared in the previous question)
Emergency contact information inside or outside the United States
Emergency contact * (if you don't have an emergency contact, write "UNKNOWN")
Is your trip to the United States in transit to another country? * (Indicate YES only IF you stop in the US without having to leave the airport and are headed to a country outside the US), for all other cases indicate DO NOT
Do you have a current or previous employer? *
Do any of the following circumstances apply to the applicant? (Answer with YES or NO)
1) You have a physical or mental disorder; or has a drug abuse problem or is a drug addict; or you currently suffer from one of the following diseases:
2) Have you ever been arrested or convicted of a crime that involved serious damage to property or another individual or government authority? *
3) Have you ever violated a law relating to the possession, use or distribution of illicit drugs? *
4) Do you intend to engage in, or have you ever engaged in, terrorist, espionage, sabotage or genocide activities? *
5) Have you ever committed fraud or made false statements about yourself or others to obtain, or to help others obtain, a visa or permit to enter the United States? *
6) Are you currently seeking employment in the United States or have you previously worked in the United States without prior authorization from the United States government? *
7) Have you ever been denied a US visa that you applied for with your current or previous passport? Or have you ever been denied entry to the United States or have you ever withdrawn your application for entry at a U.S. port of entry? *
If the answer is yes: When? Where is it?
8) Have you ever stayed in the United States longer than the period of admission you were granted by the United States government? *
Release of rights
I declare that I have read and understood and waive, for the duration of my travel authorization obtained through ESTA (Electronic System for Travel Authorization), any right to review or appeal, regarding a decision of the Customs and Border Protection officer (Office of Customs and Border Protection) relating to my eligibility, or to contest, except in cases of asylum request, any removal action resulting from an application for entry under the Visa Waiver Program Program).
In addition to the release specified above, and as a condition of each entry into the United States under the Visa Waiver Program, I acknowledge that the acceptance of biometric identifiers (including fingerprints and photographs), to upon arrival in the United States, will reaffirm my release of the rights to review or appeal a decision by the Customs and Border Protection officer regarding my eligibility, or to contest, with the exception of asylum applications, any removal action resulting from an application for entry under the Visa Waiver Program.
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