Uscis I-192, Application For Advance Permission To Enter As Nonimmigrant Page 2

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15. 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? If yes, list the applications and/or petitions, the filing locations, and describe the outcome of each application/petition (for

example: denied, approved, pending).

16. Have you ever been denied or refused an immigration benefit by the U.S. Government, or had a benefit revoked or terminated

(including but not limited to visas)? Describe in detail.

17. Have you ever, in or outside the United States, been arrested, cited, charged, indicted, fined, or imprisoned for breaking or violating any

law or ordinance, excluding minor traffic violations? Describe in detail. Include all offenses where impaired driving may have been

an issue.

18. Applicant's Signature and Certification

I understand that the information herein contained may be used in any proceedings (including civil, criminal, immigration, or any

other judicial proceeding) hereafter instituted against me.

I certify that the statements above and all attachments hereto are true and correct to the best of my knowledge and belief.

(Signature of Applicant)

(Date)

Signature of the Applicant/Signature of Guardian or Family Member (if Applicant is unable to sign)

19. Preparer's Signature and Certification

I declare that this document was prepared by me at the request of the applicant or qualified relative/legal guardian of the applicant, and it is based on

all information of which I have knowledge and/or was provided to me by the above named person in response to the exact questions contained on

this form. I have not knowingly withheld any information.

(Signature)

(Address)

(Date)

RET'D TRANS.

RECEIVED

TRANS. IN

COMPLETED

OUT

Form I-192 (Rev. 04/15/13) Y Page 2