OMB N0.

1651-0114
DEPARTMENT OF HOMELAND SECURITY Expires 10/31/2011
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 (06/09)

Arrival Place of CBP Officer Signature

Date Arrival

CREWMAN’S LANDING PERMIT

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 (06/09)
Department of Homeland Security – U.S. Customs and Border Protection
Completion of this form is mandatory pursuant to 8 U.S. C. 1281. Data is used by DHS for
alien crewman control. 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.

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

Note: Form must be typed or printed legibly.

CBP Form I-95 (06/09)