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¤J¹Ò¬ü°ê®É»Ý­n¶ñ¼g¨â¥÷ªí®æ ¡A¤@¥÷¬O¬ü°ê®üÃö¥Ó³øªí¡A¤@¥÷¬OI-94¥X¤J¹Ò¥d¡CI-94¥d«D±`­«­n¡A¯S§O¬O¦bÂ÷¶}¬ü°ê®É¡A»Ý­n¥æ´«¯èªÅ¤½¥q³ø²¾¥Á§½¡C«Ø¥ß¥X¤J¬ü°êªº¬ö¿ý¡A¤£µM±N¨Ó¦³¥i¯à³Q©Úµ´¤J¹Ò¡C

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( I-94 FORM )
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U.S. Department of Justice
OMR 1115-4077
Immigration and Naturalization service

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OMR 1115-407
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Welcome to the United State Åwªï¨Ó¨ì¬ü°ê
Admission Number
890738531 01
µn°O¸¹½X (*Á|¨Ò»¡©ú)
890738531 01
I-94 Arrival/Departure Record-Instructions I-94 ¤J¹Ò/Â÷¹Ò°O¿ý»¡©ú
This form must be completed by all persons except U.S. citizens, returning resident aliens with immigrant visas, and Canadian Citizens visiting or in transit.

°£¤F¬ü°ê¤½¥Á, ¬ü°ê®ü¥~¹´¥Á, ¥Ã¤[©~¥Á©M¥[®³¤j¤½¥Á¥~, ©Ò¦³³X°Ý ©Î¹L¸ôªº¤H¤h³£¥²¶·¶ñ¼g¦¹ªí
Type or print legibly with pen in ALL CAPITAL LETTERS. Use English. Do not write on the back of this form.
½Ð¥Î¤j¼g¦r¥À¥´¦r©Î¥Î¿ûµ§©Î¥Î¶ê¯]µ§²M·¡¶ñ¼g. ½Ð¥Î­^¤å¶ñ¼g. ¤£­n ¦b¦¹ªí­I­±¶ñ¼g¥ô¦óªF¦è.
This form is in two parts. Please complete both the Arrival Record (Item 1 through 13) and the Departure Record (Item 14 through 17).
¦¹ªí¥]¬A¨â³¡¤À, ½Ð¶ñ¼g¤J¹Ò°O¿ý (²Ä1¶µ¦Ü²Ä13¶µ)©MÂ÷¹Ò°O¿ý(²Ä 14¶µ¦Ü²Ä17¶µ)¨â³¡¤À.
When all items are completed, present this form to the U.S. Immigration and Naturalization Service Inspector.
¶ñ¼g§¹²¦«á, ½Ð±N¦¹ªí¥æµ¹¬ü°ê²¾¥Á§½©x­û.
Item 7 ¨C If you are entering the United States by land, enter LAND in this space. If you are entering the United States by ship, enter SEA in this space.
²Ä7¶µ¤º®e»¡©ú - ¦pªG§A±q³°¦a¶i¤J¬ü°ê, ½Ð¦bªÅ®æ¤º¶ñ¼gLAND, ¦pªG §A­¼²î¶i¤J¬ü°ê, ½Ð¦bªÅ®æ¤º¶ñ¼gSEA.
Form I-94(10-01-85)N
I-94ªí (10-01-85)N
Admission Number
697385031 01
µn°O¸¹½X
Immigration and Naturalization Service
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I-94
Arrival Record
I-94
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1. Family Name 1. ©m
2. First (Given) Name 2. ¦W
3. Birth Date(Day/Mo/Yr) 3. ¥Í¤é(¤ë/¤é/¦~)
4. Country of Citizenship 4. ­þ­Ó°ê®a¤½¥Á
5. Sex (Male or Female) 5. ©Ê§O(¨k Male ©Î¤k Female )
6. Passport Number 6. Å@·Ó¸¹½X
7. Airline & Flight Number 7. ¯èªÅ¤½¥q©M¯è¯Z¸¹
8. Country Where You Live 8. §A¦b­þ­Ó°ê®a©~¦í
9. City Where You Boarded 9. §A¦b­þ­Ó«°¥«­°¸¨
10. City Where Visa Was Issued 10. ¦b­þ­Ó«°¥«±o¨ìñÃÒ
11. Date Issued (Day/Mo/Yr) 11. ±o¨ìñÃÒªº¤é´Á(¤é/¤ë/¦~)
12. Address While in the United State (Number and Street) 12. ¦b¬ü°êªº¦í§}(ªùµP¸¹¤Îµó¦W)
13. City and State 13. ¦b¬ü°êªº¦í§}(¥«¦W¤Î¦{¦W)
 
Departure Number
890738531 01
Â÷¹Ò¸¹½X
890738531 01
 
Immigration and Naturalization Service ²¾¥Á§½
 
I-94
Departure Record
I-94
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14. Family Name 14. ©m
15. First (Given) Name ¡³ 16. Birth Date(Day/Mo/Yr) 15. ¦W ¡³ 16. ¥Í¤é(¤é/¤ë/¦~)
17. County of Citizenship 17. ­þ­Ó°ê®a¤½¥Á


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WELCOME TO THE UNITED STATES

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DEPARTMENT OF THE TREASURY
UNITED STATES CUSTOMS SERVICE
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CUSTOM DECLARATION ®üÃö¥Ó³ø
Each arriving traveler or head of family must provide the following information (only ONE written declaration per family is required): ¨C­Ó¤JÃöªº®È¹CªÌ©Î¤@®a¤§¥D¥²¶·´£¨Ñ¥H¤U¸ê®Æ (¤@­Ó®a®x¥u¶·¥Ó³ø¤@¥÷):
   
1. Name: 1. ©m¦W:
Last ¡³First ¡³ Middle Initial ©m ¡³ ¦W ¡³¤¤¶¡¦W
   
2. Number of family members traveling with you 2. »P§A¦P¦æªº®a®x¦¨­û¤H¼Æ:
   
3. Date of Birth:4. Airline/Flight: 3. ¥X¥Í¤é´Á: 4. ¯èªÅ¤½¥q/¯è¯Z¸¹:
Month ¡³Day ¡³Year ¤ë ¡³ ¤é ¡³ ¦~
 
5. U.S. Address: 5. ¦b¬ü©~¦í¦a§}:
 
6. I am a U.S. Citizen ¡³YES ¡³ NO 6. §A¬O¤@­Ó¬ü°ê¤½¥Á¶Ü ¬O §_
If No, Country: ¦pªG¤£¬O, §A¬O­þ­Ó°ê®aªº¤½¥Á:
 
7. I reside permanently in the U.S. ¡³ YES ¡³NO 7. §A¬O¦b¬ü°ê¥Ã¤[©~¯d¶Ü ¬O §_
If No, Expected Length of Stay: ¦pªG¤£¬O, ¹w´Á°±¯d¦h¤[:
 
8. The purpose of my trip is or was
BUSINESSPLEASURE
8. ¦¹¦¸®Èµ{ªº¥Øªº¬O
°Ó°È ®È¹C
9. I am/we are bringing fruits, plants,
¡³meats, food, soil, birds, snails, other
¡³live animals, farm products, or I/we ¡³have been on a farm or ranch outside
¡³the U.S.

YES

NO

9.9. §AÄâ±a¤ôªG, ´Óª«, ¦×Ãþ, ­¹«~, ¤gÄ[, ³¾Ãþ, ½½¤û, ¨ä¥L°Êª«©M¹A²£«~, ©Î§A ¤@ª½©~¦í¦b¬ü°ê¥H¥~ªº¹A§ø©Îªª³õ¶Ü

¬O ¡³ §_
 
10. I am/we are carrying currency or
¡³ monetary instruments over $10000
¡³ U.S. or the foreign equiralent.
YES¡³NO
10. §AÄâ±a²{ª÷©Î¬Ã¶Qª««~, ¨ä»ù­È¶W¹L¤@ ¸U¬üª÷©Î¬Û·í©ó¤@¸U¬üª÷ªº¥~¹ô¶Ü ¬O ¡³§_
 
11. The total value of all goods I/we purchased or
¡³acquired abroad and am/are bringing to the U.S.
¡³is (see instructions under Merchandise on
¡³reverse side; visitors should report value of gifts
¡³only):¡³$___________________ U.S. Dollars
11. §A¹Ò¥~ÁʶR©ÎÀò±o¨Ã±a¤J¬ü°ê©Ò¦³ª««~Á`»ù­È(°Ñ¬Ý ­I­±°Ó«~Äæ¥Ø; ³X°ÝªÌ¥u¶·¥Ó³øÂ§«~»ù­È): $ _________________ ¬ü¤¸
 
SIGN ON RESERSE SIDE AFTER YOU READ WARNING.(Do not write below this line.) ¦b§A¾\Ūĵ§i¤§«á½Ð¦b­I­±Ã±¦r(¤£­n¦b¦¹½u¤U­±Ã±¦r)
INSPECTOR¡¯S NAME STAMP AREA À˹î­û©m¦W »\³¹°Ï°ì
 
BADGE NO À²³¹¸¹½X

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