Entry Permit Waiver 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 personnel will use this information to determine every 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 OK Board

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

E-mail*

Confirmation Emailexample@example.com

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

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

Full Name of Host*

Host Email*

example@example.com

Phone number of Host*

Area CodePhone Number

Village*

Please upload Host Local ID*

Browse Files

Please upload Recent Utility Bill*

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 OKBoard to hand carry upon check-in)*

example@example.com

Passport Country of Issue**

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

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, Traveler/Host certifies that the facts contained in this application are true and complete to the best of my knowledge 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 immediate removal.

Additionally, by clicking the submit button below, I 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 I 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 EPWP does not guarantee approval of an EPWP 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.

PENALTIES
A. Any traveler under the Entry Permit Waiver Program who stays in American Samoa beyond the time allowed will not be qualified in the future for entry to American Samoa under the Entry Permit Waiver Program and is subject to a fine of $100 (USD) per day for each day traveler overstays in American Samoa.

B. Any host under the Entry Permit Waiver Program who fails to comply with Host responsibilities under the Entry Permit Waiver Program will not be qualified in the future to be a host under the Entry Permit Waiver Program and is subject to a maximum fine of $500 (USD).

C. Any traveler or host who provides false information in an application under the Entry Permit Waiver Program will be subject to penalties under the law and will be disqualified in the future from participating in the Entry Permit Waiver Program.

Furthermore, by clicking "Submit", I also agree that the $40 (USD) application fee is non-refundable.

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 said travel authorization (OK Board) and present it to a local immigration officer on demand.

Permit Waiver

Permit Waiver$40.00

Total $0.00

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

ENTRY PERMIT WAIVER APPLICATION

Traveler's Personal Information

Traveler's Address & Contact Information

Travel Information

Required Documents

Submission