06/01/2024 16:06 Official ESTA Application Website, U.S.
Customs and Border Protection
Official Website of the Department of Homeland Security
AUTHORIZATION APPROVED Download Print Close
Your travel authorization has been approved and you are authorized to travel to the United States under the Visa Waiver
Program. This does not guarantee admission to the United States; a Customs and Border Protection (CBP) officer at a port of
entry will have the final determination.
APPLICATION NUMBER EXPIRATION DATE
140M02307R0155F7 05/30/2025
PAYMENT RECEIPT
Payment Date: May 30, 2023 4:16:21 PM
Payment Tracking Code: 275OU72G
Payment Received: $21.00
APPLICANT INFORMATION
Family Name First (Given) Name Passport Number
KOWALKOWSKI MATHILDE ALICE 20DC68331
Issuing Country Issuance Date Expiration Date
FRANCE (FRA) July 8, 2020 July 7, 2025
Country of Citizenship / Nationality National Identification Number Personal Identification Number
FRANCE (FRA)
Sex Date of Birth City of Birth
Female March 17, 2006 SAINT-MARTIN-D'HERES
Country of Birth
FRANCE (FRA)
OTHER CITIZENSHIP/NATIONALITY
Are you now, a citizen or national of any other country? No
Confidentialité - Conditions
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Have you ever been a citizen or national of any other country? No
E-mail Address Confirm E-mail Address
[Link]@[Link] [Link]@[Link]
M M
PERSONAL INFORMATION
Are you known by any other names or aliases? No
Have you ever been issued a passport or national identity card for travel by any other country? No
YOUR CONTACT INFORMATION
Address Line 1 Address Line 2 Apartment Number
1 RUE SAINT FRANCOIS 516
City State/Province/Region Country
GRENOBLE ISERE FRANCE (FRA)
Telephone Type Country Code Phone Number
Mobile FRANCE METROPOLITAN (FXX) (+33) 769077095
Telephone Type Country Code Phone Number
Mobile FRANCE METROPOLITAN (FXX) (+33) 648805832
Telephone Type Country Code Phone Number
Mobile FRANCE METROPOLITAN (FXX) (+33) 652348243
SOCIAL MEDIA (OPTIONAL)
Provider / Platform Social Media Identifier
Instagram [Link]
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GE/NEXUS/SENTRI MEMBERSHIP
Are you a member of the CBP Global Entry/NEXUS/SENTRI Program? No
PARENTS
Family Name First (Given) Name
HERNANDEZ BETHSABEE
Family Name First (Given) Name
KOWALKOWSKI ALEXANDRE
EMPLOYMENT INFORMATION
Do you have a current or previous employer? No
TRAVEL INFORMATION
Is your travel to the US occurring in
transit to another country? No
U.S. Point of Contact Information
Name
UDELMAN
Address Line 1 Address Line 2 Apartment Number
1033 E KALER DRIVE
City State/Province/Region
PHOENIX ARIZONA
Country Code Phone Number
UNITED STATES (USA) (+1) 4808095421
Address While in the U.S.
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Address Line 1 Address Line 2 Apartment Number
319 W 48TH ST THE BELVEDERE HOTEL
City State/Province/Region
NEW YORK NEW YORK
EMERGENCY CONTACT INFORMATION IN OR OUT OF THE U.S.
Family Name First (Given) Name E-mail Address
UDELMAN RANDALL RUDELMAN@[Link]
Country Code Phone Number
UNITED STATES (USA) (+1) 4808095421
ELIGIBILITY QUESTIONS
1) Do you have a physical or mental disorder; or are you a drug abuser or addict; or do you currently No
have any of the following diseases (communicable diseases are specified pursuant to section 361(b)
of the Public Health Service Act):
Cholera
Diphtheria
Tuberculosis, infectious
Plague
Smallpox
Yellow Fever
Viral Hemorrhagic Fevers, including Ebola, Lassa, Marburg, Crimean-Congo
Severe acute respiratory illnesses capable of transmission to other persons and likely to
cause mortality.
2) Have you ever been arrested or convicted for a crime that resulted in serious damage to property, No
or serious harm to another person or government authority?
3) Have you ever violated any law related to possessing, using, or distributing illegal drugs? No
4) Do you seek to engage in or have you ever engaged in terrorist activities, espionage, sabotage, or No
genocide?
5) Have you ever committed fraud or misrepresented yourself or others to obtain, or assist others to No
obtain, a visa or entry into the United States?
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6) Are you currently seeking employment in the United States or were you previously employed in the No
United States without prior permission from the U.S. government?
7) Have you ever been denied a U.S. visa you applied for with your current or previous passport, or No
have you ever been refused admission to the United States or withdrawn your application for
admission at a U.S. port of entry?
8) Have you ever stayed in the United States longer than the admission period granted to you by the No
U.S. government?
9) Have you traveled to, or been present in Iran, Iraq, Libya, North Korea, Somalia, Sudan, Syria or No
Yemen on or after March 1, 2011?
Paperwork Reduction Act: An agency may not conduct or sponsor an information collection and a person is not required
to respond to this information unless it displays a current valid OMB control number and an expiration date. The control
number for this collection is 1651-0111. The estimated average time to complete this application is 23 minutes. If you
have any comments regarding this burden estimate you can write to U.S. Customs and Border Protection, Office of
Regulations and Rulings, 90 K Street, NE, 10th Floor, Washington DC 20229. Expiration May 31, 2026.
The ESTA logo is a registered trademark of the U.S. Department of Homeland Security. Its use, without permission, is
unauthorized and in violation of trademark law. For more information, or to request the use of the logo, please go to
[Link] ([Link] and submit a request by clicking on "Ask a Question." When selecting the Product (under
Additional Information) use "ESTA" and the sub-product "Logo Assistance" to expedite handling of your request.
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