1. Family Name 姓

2. First (Gicen) Name 名

3. Birth Date (day/mo/yr)

出生日期（日/月/年）

4. Country of Citizenship 国籍

5.Sex (Male or Female)

性别（男或女）

C

H

I

N

E

S

E

6.Passport Number 护照号

7.Airline and Flight Number航班号

8.Country Where You Live居住的国家

9.City Where You Boarded居住的城市

C

H

I

N

A

10.City Where Visa Was Issued获得签证的城市

11.Date Issued (day/mo/yr)

签证日期（日/月/年）

12.Address While in the United States (Number and Street)在美地址（含街道和门牌号）

13.City and State（上述地址所在）城市和州

1. Family Name 姓

2. First (Gicen) Name 名

3. Birth Date (day/mo/yr)

出生日期（日/月/年）

4. Country of Citizenship 国籍

C

H

I

N

E

S

E

1. Family Name 姓

First (Given) 名

Middle中间名

2. Birth date 出生日期 Day日

Month月

Year年

3. Number of Family Members traveling with you. 和你同行的家人人数

4. ⒜U.S. Street Address(hotel name/destination).在美国的地址（酒店名/目的地）

⒝City城市

⒞State州

5. Passport issued by (country)护照颁发国

CHINA

6. Passport number护照号

7. Country of Residence居住国

CHINA

8. Countries visited on this Trip prior to U.S. arrival

NONE

此次到美国之前访问的国家

9. Airline/Flight No. or Vessel Name 航班或船班号

10. The primary purpose of thip is business:这次旅行主要的目的是工作

Yes

No

11. I am (We are) bringing我（我们）携带了

⒜ fruits, plants, food, insects:水果，农产品，食品，昆虫

Yes

No

⒝ meats, animals, animal/wildlife products:肉类，动物，动物/野生动物制品

Yes

No

⒞ disease agents, cell cultures, snails: 蜜蜂制品，生物制品

Yes

No

⒟soil or have been on a farm/ranch/pasture:来自农场/牧场/草原的土壤

Yes

No

12. I have(we have) been in close proximity of (such as touching or handing) livestock:

我（我们）最近接近过牲畜。

Yes

No

13. I am (We are) carrying currency or monetary instruments over $10,000 U.S.or foreign equivalents (see definition of mone tary instruments on reverse)

我（我们）携带了超过10000美元或等值外币。

Yes

No

14. I have (We have) commercial merchandise:（(articles for sale, samples used for soliciting orders, or goods that are not considered personal effects)

我（我们）有商务货品（商品、样品或非个人使用的物品）

Yes

No

15. Residents – the total value of all goods, including commercial merchandise I/we have purchased or acquired abroad, (including gifts for someone else, but not items mailed to the U.S.) and am/are bringing to the U.S. is:

美国公民——从国外购买或获得的商品（包括礼品）的总价值： $

Visitors – the total value of all articles that will remain in the U.S., including commercial

merchandise is:访问者——所有将留在美国的商品总价值： $

Read the instructions on the back of this form. Space is provided to list all the items you must

declare.参见本表背面的说明，并在空白出列出物品的清单。

IHAVE READ THE IMPORTANT INFORMATION ON THE REVERSE SIDE OF THIS FORM AND HAVE MADE A TRUTHFUL DECLARATION.

我已阅读了本表背面的注意事项，并已如实申报。

(Signature)签名 Date (day/month/year)日期（日/月/年）