Fillable Form I-95 Crewman'S Landing Permit printable pdf download

Form I-95 Crewman'S Landing Permit

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OMB No. 1651-0114

DEPARTMENT OF HOMELAND SECURITY

Expires 06/30/2018

U.S. Customs and Border Protection

FIN or “A” No.

CREWMAN’S LANDING PERMIT

Family Name

Given Name

Initial

Home Address

Address in United States

Hair

Eyes

Ht.

Wt.

Date of Birth

Place of Birth

Passport Number/Nationality

Arrived by

Air

Sea

CBP Form I-95 (02/12)

CREWMAN’S LANDING PERMIT

Department of Homeland Security – U.S. Customs and Border Protection

5 U.S.C. § 552a (e)(3) Privacy Act Notice: Information collected on this form is required by Title 8 of the U.S.

Code, specifically the Immigration and Nationality Act (8 U.S.C. 1282) and 8 CFR 251.1(c), 252.1(e) and 264.1.

The purpose of this collection is to provide for the application and approval of alien crew members for

permission to temporarily land in the United States. The information solicited on this form will be used to assist

DHS in determining your eligibility for such privileges and may be made available to other government agencies

for law enforcement purposes, as necessary. All alien crew members seeking to land in the U.S., unless

otherwise excepted, must provide this information. Failure to provide this information may result in a denial to

land in the United States and result in your removal.

Paperwork Reduction Act Statement: An agency may not conduct or sponsor an information collection and a

person is not required to respond to this information unless it displays a current valid OMB control number and

an expiration date. The control number for this collection is 1651-0114. The estimated average time to complete

this application is 5 minutes. If you have any comments regarding the burden estimate you can write to U.S.

Customs and Border Protection, Office of Regulations and Rulings, 799 9th Street, NW., Washington DC 20229.

CBP Form I-95 (02/12)

Arrival Date

Place of Arrival

CBP Officer Signature

By accepting this conditional permit to land, the holder agrees to all the

conditions incident to the issuance thereof and to deportation from the United

States in accordance with the provisions of section 252(b) of the Immigration and

Nationality Act.

CBP Form I-95 (02/12)

Form I-95 Crewman'S Landing Permit

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