US Visa 30 Day Application(Stripe)

Legal Notice

Authority: The American Samoa Code Annotated Section 41.0207 authorizes the collection of the information and/or documents requested herein.

Purpose: To allow collection and recording of information regarding every person leaving or entering American Samoa.

Routine Use: The American Samoa Government - Department of Legal Affairs will use this information to determine an individual's eligibility to enter American Samoa. Additionally, the Attorney General may share this information with other law enforcement agencies, applicable government agencies or persons, as necessary.

Disclosure: Furnishing the requested information is voluntary, however, failure to furnish the requested information or documents may prevent completion of your application for an entry authorization.

*Cruise ship passengers are exempted; do NOT apply for an Permit

Full Name*

First NameMiddle NameLast Name

Date of Birth*

MonthDayYear

Gender*

MaleFemale

Have you ever been convicted of a felony in any country?*

YesNo

If yes, where and when?

Have you ever been convicted of two crimes in any country?*

YesNo

If yes, where and when?

Current Address*

Street Address

Street Address Line 2

CityState

Country

Phone Number*

Area CodePhone Number

Reason for travel to Am. Samoa*

Business

Tourism

If for medical treatment, please specify.*

0/75

If, other, please explain.*

0/75

Date of Arrival*

MonthDayYear

Date Departing Am. Samoa*

MonthDayYear

Accommodations*

HotelHost

Name of Hotel*

Phone Number of Hotel*

Area CodePhone Number

Upload confirmed hotel booking*

Browse Files

Local Point of Contact*

First NameLast Name

Local Phone Number (with 684 area code)*

Area CodePhone Number

Village*

Host must be 21 years old and is the owner of the home or lessee of an apartment

Full Name of Host*

Phone number of Host*

Area CodePhone Number

Village*

Please upload Host Local ID *

Browse Files

Please upload Recent Utility Bill (Host's name must be on the Utility Bill that is being attached)*

Browse Files

Please upload Lease Agreement (If host lives in an apartment)

Browse Files

Who is filling out the application?*

TravelerHost

Signature of Traveler or Host*

Email (Please check this email for the approved Permit to hand carry upon check-in)*

example@example.com

Passport Country of Issue**

* United Kingdom includes England, Northern Ireland, Scotland and Wales.

Upload Copy of Traveler's US Visa or Green Card*

Browse Files

Expiration Date of Passport*

Date

Please upload a copy of your ticket or itinerary and Passport. Once you submit your application, you will receive an email from our office confirming receipt of your application with further instructions before we forward you a copy of your travel authorization document (OK Board).

Upload Copy of Traveler's RoundTrip Ticket or Itinerary*

Upload a File

Upload Copy of Traveler's Passport/Travel Documents*

Upload a File

By clicking the submit button below, you certify that the facts contained in this application are true and complete to the best of yourknowledge and understand that, if allowed to enter American Samoa, false statements on this application shall be grounds to refuse entry into any port of entry in American Samoa, or for your immediate removal.

Additionally, by clicking the submit button below, you authorize investigation of all statements, claims, or information contained herein and the reference listed above to give the American Samoa Government any and all information concerning my visit to American Samoa and any pertinent information they may have, personal or otherwise, and you hereby release the American Samoa Government from any and all liability for any damage that may result from utilization of such information.

Eligibility under the US Visa 30 Day Visitor Permit does not guarantee approval of your application or entry into American Samoa. Immigration officers may refuse entry at the port of entry based on American Samoa laws. A traveler who poses a threat to the welfare, health, safety or security of American Samoa will be denied entry and placed back on the arriving vessel to be returned to the point of origin.

Important Note

Please take note that submission and acceptance of your application does not constitute automatic approval thereof. Allow at least 3 business days to process your request. Only an affirmative correspondence from our office explicitly indicating approval of your submission is valid. You are required to print out a copy of the US Visa 30 DayPemit and present it to a local immigration officer on demand.

Permit

Permit $40.00

Total $0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

US VISA 30 DAY VISITOR PERMIT APPLICATION

Traveler's Personal Information

Traveler's Address & Contact Information

Travel Information

Required Documents

Submission