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1. Family Name ÐÕ 2. First (Gicen) Name Ãû 3. Birth Date (day/mo/yr) ³öÉúÈÕÆÚ£¨ÈÕ/ÔÂ/Ä꣩ 4. Country of Citizenship ¹ú¼® 5.Sex (Male or Female) ÐÔ±ð£¨ÄлòÅ®£© 6.Passport Number »¤ÕպŠ7.Airline and Flight Number º½°àºÅNumberHANGº½°àºÅ 8.Country Where You Live¾ÓסµÄ¹ú¼Ò 9.City Where You Boarded¾ÓסµÄ³ÇÊÐ 10.City Where Visa Was Issued»ñµÃǩ֤µÄ³ÇÊÐ 11.Date Issued (day/mo/yr) ǩ֤ÈÕÆÚ£¨ÈÕ/ÔÂ/Ä꣩ 12.Address While in the United States (Number and Street)ÔÚÃÀµØÖ·£¨º¬½ÖµÀºÍÃÅÅÆºÅ£© 13.City and State£¨ÉÏÊöµØÖ·ËùÔÚ£©³ÇÊкÍÖÝ

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1. Family Name ÐÕ 2. First (Gicen) Name Ãû 3. Birth Date (day/mo/yr) ³öÉúÈÕÆÚ£¨ÈÕ/ÔÂ/Ä꣩ 4. Country of Citizenship ¹ú¼® ÃÀ¹úº£¹ØÉ걨±í 1. Family Name ÐÕ First (Given) Ãû MiddleÖмäÃû MonthÔ 2. Birth date ³öÉúÈÕÆÚ DayÈÕ YearÄê 3. Number of Family Members traveling with you. ºÍÄãͬÐеļÒÈËÈËÊý 4. ?U.S. Street Address(hotel name/destination).ÔÚÃÀ¹úµÄµØÖ·£¨¾ÆµêÃû/Ä¿µÄµØ£© ?City³ÇÊÐ 5. Passport issued by (country)»¤ÕÕ°ä·¢¹ú 6. Passport number»¤ÕպŠ7. Country of Residence¾Óס¹ú ?StateÖÝ 8. Countries visited on this Trip prior to U.S. arrival ´Ë´Îµ½ÃÀ¹ú֮ǰ·ÃÎʵĹú¼Ò 9. Airline/Flight No. or Vessel Name º½°à»ò´¬°àºÅ Yes No 10. The primary purpose of thip is business:Õâ´ÎÂÃÐÐÖ÷ÒªµÄÄ¿µÄÊǹ¤×÷ 11. I am (We are) bringingÎÒ£¨ÎÒÃÇ£©Ð¯´øÁË ? fruits, plants, food, insects:Ë®¹û£¬Å©²úÆ·£¬Ê³Æ·£¬À¥³æ Yes No ? meats, animals, animal/wildlife products:ÈâÀ࣬¶¯Î¶¯Îï/Ò°Éú¶¯ÎïÖÆÆ· Yes No ? disease agents, cell cultures, snails: ÃÛ·äÖÆÆ·£¬ÉúÎïÖÆÆ· ?soil or have been on a farm/ranch/pasture:À´×ÔÅ©³¡/ÄÁ³¡/²ÝÔ­µÄÍÁÈÀ Yes No Yes No 12. I have(we have) been in close proximity of (such as touching or handing) livestock: ÎÒ£¨ÎÒÃÇ£©×î½ü½Ó½ü¹ýÉüÐó¡£ Yes No 13. I am (We are) carrying currency or monetary instruments over $10,000 U.S.or foreign equivalents (see definition of monetary instruments on reverse) ÎÒ£¨ÎÒÃÇ£©Ð¯´øÁ˳¬¹ý10000ÃÀÔª»òµÈÖµÍâ±Ò¡£ 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) ÎÒ£¨ÎÒÃÇ£©ÓÐÉÌÎñ»õÆ·£¨ÉÌÆ·¡¢ÑùÆ·»ò·Ç¸öÈËʹÓõÄÎïÆ·£© Yes No 15. Residents ¨C 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: ÃÀ¹ú¹«Ãñ¡ª¡ª´Ó¹úÍ⹺Âò»ò»ñµÃµÄÉÌÆ·£¨°üÀ¨ÀñÆ·£©µÄ×ܼÛÖµ£º $ Visitors ¨C the total value of all articles that will remain in the U.S., including commercial merchandise is:·ÃÎÊÕß¡ª¡ªËùÓн«ÁôÔÚÃÀ¹úµÄÉÌÆ·×ܼÛÖµ£º $ Read the instructions on the back of this form. Space is provided to list all the items you must declare. ²Î¼û±¾±í±³ÃæµÄ˵Ã÷£¬²¢Ôڿհ׳öÁгöÎïÆ·µÄÇåµ¥¡£ IHAVE READ THE IMPORTANT INFORMATION ON THE REVERSE SIDE OF THIS FORM AND HAVE MADE A TRUTHFUL DECLARATION. ÎÒÒÑÔĶÁÁ˱¾±í±³ÃæµÄ×¢ÒâÊÂÏ²¢ÒÑÈçʵÉ걨¡£ (Signature)Ç©Ãû Date (day/month/year)ÈÕÆÚ£¨ÈÕ/ÔÂ/Ä꣩

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