USA ESTA application form

Attention: if this field is filled in, it has to be done in English.

Illnesses
You are required to answer this question with "Yes" if this traveller currently suffers from one or several of the following illnesses:

• Cholera
• Dysentery
• Contagious tuberculosis
• Plague
• Pocks
• Yellow fever
• Viral haemorrhaging viral fevers, including Ebola, Lassa, Marburg, Crimean–Congo
• Severe acute respiratory afflictions which can be transferred to others and are likely to cause death.

Physical or mental afflictions
You are also required to answer this question with "Yes" if:

• This traveller currently has a physical or mental affliction, and a history of behaviour related to the affliction which can pose, or has posed, a threat to his or her belongings, safety or welfare, or that of others; or
• The traveller has had a physical or mental affliction, and has a history of behaviour related to this affliction which has posed a threat to his or her properties, safety, or welfare, or that of others, and that behaviour has a large chance of repeat or can lead to other damaging behaviour. Answer "No" if:
  • This traveller currently does not have physical or mental afflictions; or
  • The traveller has, or has had, a physical or mental affliction without associated behaviour which can pose a threat to their properties, safety or welfare, or that of others; or
  • The traveller currently has a physical or mental affliction with associated behaviour, but that behaviour does not pose a danger, has not posed a danger, and will not pose a danger to their properties, safety or welfare, or that of others, or;
  • The traveller has had a physical or mental affliction with associated behaviour which has posed a threat to their belongings, safety or welfare, or that of others, but this behaviour does not have a large chance of repeat.

Drug users and drug addicts
You are also required to answer this question with "Yes" if the traveller is a user of, or addicted to, drugs/narcotics.
For more information about the admission requirements with regards to narcotics, you can consult paragraph 212 and 1182 of the Immigration and Nationality Act 8 USC, as well as the regulations of the Code of Federal Regulations.

Do you have a criminal record? This does not necessarily mean you cannot apply for an ESTA. Only if you have been convicted of a crime that has resulted in serious material damage or serious injury to another person, or damage to a government agency, are you unable to apply for an ESTA. Offences such as traffic offences or (traffic) fines do not prevent you from applying for an ESTA, unless they led to serious material damage or serious injury to another person.

For more information about the admission requirements with regards to narcotics, you can consult paragraph 212 and 1182 of the Immigration and Nationality Act 8 USC, as well as the regulations of the Code of Federal Regulations.

Travellers can only apply for an ESTA if they agree to all the terms in this statement. Are you filling in the form on behalf of someone else? Read this statement out in full to the person in question. Then, indicate in the form whether this person agrees to it.

I, the traveller to whom this part of the ESTA form relates, hereby state that:

• I have read and understood all the questions and answers in the ESTA form which relate to me as well as this statement, or have had it read to me,
• I have truthfully and in good conscience filled in the part of the ESTA form that relates to me with up-to-date and correct information,
• I understand and accept that the validity of an ESTA can at all times be withdrawn without a reason needing to be provided, for example (but not exclusively) based on new information, which affects the qualification for an ESTA,
• I understand and accept that I can be subjected to administrative or criminal sanctions if a false statement or presentation of facts is knowingly and intentionally provided in an ESTA application submitted by me or in my name,
• during my entire stay in the United States on an ESTA travel authorisation, I will not accept any work, will not enter into employment, will not follow an education and will not represent foreign media,
• during my stay in the United States, I will not submit an application to change my non-immigrant status, or apply for an extension of the maximum length of stay, or apply for a temporary or permanent resident permit, unless I qualify for it based on article 245(c)(4) of the Immigration and Nationality Act,
• I understand that a possible rejection of my ESTA travel authorisation does not exclude the possibility to apply for a visa to travel to the United States,
• I wave all rights for the entirety of the validity term of the ESTA to review or appeal the decision of (an employee of) U.S. Customs & Border Protection regarding my admissibility, or to, other than based on an asylum application, fight deportation procedures that issue from an application for admission under the Visa Waiver Program,
• I understand and accept that granting of my ESTA application does not guarantee that I am allowed into the United States under the Visa Waiver Program, as an employee of U.S. Customs & Border Protection can deny me entry to the United States on arrival if they see cause to do so, without needing to provide a reason,
• on arrival in the United States I will allow biometric identification to be taken by U.S. Customs & Border Protection, including fingerprints and photos, with which I will again confirm to agree with the terms in this statement,
• I will allow U.S. Customs & Border Protection to perform checks during the assessment of an ESTA application based on law enforcement databases,
• I agree and accept that if found in violation of this statement I will be DEPORTED from the United States

1. Point of contact unknown
If you currently do not know a :

• friend
• family member
• colleague
• place to stay (if established)
• or other point of contact

in the US, click here to automatically fill in these fields with UNKNOWN.

2. Point of contact known
If you do have a point of contact in the US, you can fill in the information of it.