Visa Waiver Stay Extension Request

Visa Waiver Stay Extension Request
Request an extension of your stay under the visa waiver program. Please complete all required fields accurately.
Full Name
First NameLast Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Nationality
The Last 4 Digits of Your Passport
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Current Address During Stay
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Arrival
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Original Departure Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Requested New Departure Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reason for Extension Request
Upload Supporting Documents (e.g., proof of need, travel itinerary)
Cancelof
Should be Empty: