Application for Replacement/Initial Nonimmigrant Arrival-Departure Document

• Legal Form Number: I-102
• Section: Citizenship and Immigration Services (United States of America)
• Issuer: Citizenship and Immigration Services (United States of America)

Form I-102 Edition 12/02/21 Page 1 of 6

Application for Replacement/Initial Nonimmigrant

Arrival-Departure Document

Department of Homeland Security

U.S. Citizenship and Immigration Services

For

USCIS

Use

Only

Action Block

►START HERE. Type or print in black ink

Part 1. Information About You

USCIS

Form I-102

OMB No. 1615-0079

Expires 12/31/2023

To Be Completed by an

Attorney or Accredited

Representative,

if any.

Select this box if Form

G-28 is attached to

represent the applicant.

Attorney State

License Number

3.b.

3.c.

3.a. Family Name

(Last Name)

Given Name

(First Name)

Middle Name

New I-94 Number

Remarks

Receipt

ZIP Code

5.f.

State

5.e.

City or Town5.d.

Street Number and Name5.b.

5.c Ste. Flr.Apt.

If you answered "No" to Item Number 6., provide your

U.S. physical address in Item Numbers 7.a. - 7.f.

6. Is your current U.S. mailing address the same as your

U.S. physical address? Yes No

►A-

Alien Registration Number (A-Number)1.

USCIS Online Account Number (if any)2.

►

Your Full Legal Name

7.a.

U.S. Physical Address

In Care Of Name

ZIP Code

7.f.

State

7.e.

City or Town7.d.

Street Number and Name7.b.

7.c. Ste. Flr.

Apt.

Family Name

(Last Name)

4.a.

Given Name

(First Name)

4.b.

Middle Name4.c.

Provide all other names used. Include nicknames, aliases,

maiden name, and names from previous marriages. Provide

evidence of any name changes.

Other Names Used (if any)

5.a.

U.S. Mailing Address

In Care Of Name 8. Date of Birth (mm/dd/yyyy)

Other Information

10. Country of Citizenship

9. Country of Birth