Form DS-4024 Travel Registration

OMB APPROVAL NO. 1405-0152
EXPIRATION DATE: 10/31/2006
ESTIMATED BURDEN: 10 Minutes

U.S. Department of State

TRAVEL REGISTRATION

Travel registration is a free service provided by the U.S. Government to U.S. citizens who are traveling to, or living in, a foreign country.
Registration allows you to record information about your trip abroad that the U.S. Department of State can use to assist you in case of an
emergency. To register your trip or foreign residence, please fill out the form below and return to the U.S. Department of State.
Personal Information:
Fill out your Personal Information
First Name

Last Name

Middle Name

Address Line 1
Address Line 2
City

U.S. State or Foreign Province

Country

Postal Code

Phone Number

Fax Number

Date of Birth (mm-dd-yyyy)
Marital Status

E-Mail Address
Citizenship

Gender

Occupation

Passport Date of
Issue (mm-dd-yyyy)

Passport Date of
Expiration (mm-dd-yyyy)

Passport Information:
Passport Number
Passport Place of Issue
Emergency Contact Information (Next of Kin):
Fill out your Emergency Contact Information. Your Emergency Contact should be someone who is not traveling or living with you.
First Name

Middle Name

Last Name

Address Line 1
Address Line 2
City

U.S. State or Foreign Province

Country

Postal Code

Phone Number

Fax Number

E-Mail Address

Relationship to Primary Traveler/Resident
Business Information:
If you have a business address, please fill in your contact information.
First Name

Middle Name

Last Name

Address Line 1
Address Line 2
City

U.S. State or Foreign Province

Country

Postal Code

Phone Number

Fax Number

E-Mail Address

Paperwork Reduction Act Statements
Public reporting burden for this collection of information is estimated to average 10 minutes per response, including time required for searching existing data
sources, gathering the necessary documents, providing the information or documents required, and reviewing the final collection. You do not have to supply this
information unless this collection displays a valid Office of Management and Budget (OMB) number. If you have comments on the accuracy of this burden
estimate or recommendations for reducing it, please send them to: Information Collection Coordinator, U.S. Department of State, A/RPS/Dir, Washington, DC
20520.

Privacy Act Information
Fill out your Privacy Act information. You must check the check box to indicate that you have read the Privacy Act Notice.
The U.S. Department of State is committed to ensuring that any personal information received by our overseas embassies and consulates pursuant to the
registration process, whether in person or otherwise, is safeguarded against unauthorized disclosure. The data that you provided the U.S. Department of State is
subject to the provisions of the Privacy Act (5 USC 552a). This means that the U.S. Department of State will not disclose the information you provide us in your
registration application to any third parties unless you have given us written authorization to do so, or unless the disclosure is otherwise permitted by the Privacy
Act.

AUTHORITY 22 U.S.C. 2715, and 22 U.S.C. 4802(b).
PURPOSE To notify U.S. citizens in the event of a disaster, emergency or other crisis, issuance of a travel warning, public announcement or consular
information sheet, and for evacuation coordination. The information solicited on this form may be made available as a routine use to appropriate agencies
whether federal, state, local, or foreign, to assist the Department in the evacuation or provision of emergency service to U.S. citizens, or for law enforcement
and administration purposes or pursuant to court order. The information is also made available to private U.S. citizens, known as wardens, designated by U.S.
embassies to assist in communicating with the American community in an emergency. For a complete statement of the routine uses to which this information
may be put, see the Prefatory Statement of Routine Uses and the listing of routine uses set forth in the systems description for Overseas Citizens Services
Records (State-05), found at http://foia.state.gov/issuances/priviss.asp. Lastly, while this internet site uses secure encryption to safeguard your privacy and
therefore any unauthorized interception by third parties of the information you send via the internet is unlikely, please keep in mind that the U.S. Department of
State is not responsible for any such interception.
I have read the terms of the Privacy Act Notice.

DS-4024
05-2006

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I agree to allow the U.S. Department of State to disclose my information to:
Family Members
Friends
Legal Representative
Media
Other
Members of Congress
Medical Representative
Waiver Comments Please use this space below to specify individuals, explain, or clarify your response or describe your selection of "Other"

OR
I do not authorize the U.S. Department of State to disclose my information to anyone except as authorized by law.

Itinerary

Please provide enough information about your Destination or Overseas Residence to help a U.S. consular officer contact you in case of an
emergency. The Type of Visit, Destination, Date of Arrival, Destination, Date of Departure (except for Indefinite Stay visits), and Country must
be entered. For example, providing the hotel name, the city, and the country will be useful, even if you can not provide the hotel phone
number. Please provide the dates you will be in that location, even if approximate.
Type of Visit (Select One)

Destination Date (mm-dd-yyyy) of Arrival

Purpose of Visit

Extended Stay
Indefinite Stay
Frequent Visit

Destination Date (mm-dd-yyyy) of Departure (If Any)

One-Time Visit
Destination Information
(Select One) (Additional
destination information may
be included on pages 3 and
4.)
Address Line 1

Destination Type (Select One)
Home

Hotel

School

Other

Address Line 2
City

Foreign State or Province

Country

Postal Code

Phone Number

Fax Number

E-Mail Address

Additional Travelers/Members of Household
If you are traveling or residing with one or more travelers/members of household, please fill out their Personal Information below. Attach
additional copies of this form if you need more space.
Additional Traveler/Member of Household #1:
First Name

Middle Name

Last Name

Address Line 1
Address Line 2
City

U.S. State or Foreign Province

Country

Postal Code

Phone Number

Fax Number

Date of Birth (mm-dd-yyyy)

Citizenship

E-Mail Address
Relationship to Primary Traveler/Resident

Comments
Passport Number

Passport Date of Issue (mm-dd-yyyy)

Passport Date of Expiration (mm-dd-yyyy)

Passport Place of Issue
DS-4024

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Additional Travelers/Members of Household:
If you are traveling or residing with one or more travelers/members of household, please fill out their Personal Information below. Attach
additional copies of this form if you need more space.
Additional Traveler/Member of Household #2:
First Name

Middle Name

Last Name

Address Line 1
Address Line 2
City

U.S. State or Foreign Province

Country

Postal Code

Phone Number

Fax Number

Date of Birth (mm-dd-yyyy)

Citizenship

E-Mail Address
Relationship to Primary Traveler/Resident

Comments
Passport Number

Passport Date of Issue (mm-dd-yyyy)

Passport Date of Expiration (mm-dd-yyyy)

Passport Place of Issue
Additional Traveler/Member of Household #3:
First Name

Middle Name

Last Name

Address Line 1
Address Line 2
City

U.S. State or Foreign Province

Country

Postal Code

Phone Number

Fax Number

Date of Birth (mm-dd-yyyy)

Citizenship

E-Mail Address
Relationship to Primary Traveler/Resident

Comments
Passport Number

Passport Date of Issue (mm-dd-yyyy)

Passport Date of Expiration (mm-dd-yyyy)

Passport Place of Issue

If there are any additional destinations, please complete the required information below.
Additional Destination Information
If you are visiting more than one city or country during your trip, enter details about your destination that could help a consular officer contact
you in case of an emergency. Attach additional copies of this form if you need more space.
Additional Destination #1:

Destination Date (mm-dd-yyyy) of Arrival

Purpose of Visit

Type of Visit (Select One)
Extended Stay
Indefinite Stay

Destination Date (mm-dd-yyyy) of Departure (If Any)

Frequent Visit
One-Time Visit
Destination Information:

Destination Type (Select One)
Home

Hotel

School

Other

Address Line 1
Address Line 2
City

Foreign State or Province

Country
Phone Number

DS-4024

Postal Code
Fax Number

E-Mail Address

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Additional Destination Information:
If you are visiting more than one city or country during your trip, enter details about your destination that could help a consular officer contact
you in case of an emergency. Attach additional copies of this form if you need more space
Additional Destination #2:

Destination Date (mm-dd-yyyy) of Arrival

Purpose of Visit

Type of Visit (Select One)
Extended Stay
Indefinite Stay

Destination Date (mm-dd-yyyy) of Departure (If Any)

Frequent Visit
One-Time Visit
Destination Information:

Destination Type (Select One)
Home

Hotel

School

Other

Address Line 1
Address Line 2
City

Foreign State or Province

Country

Postal Code

Phone Number
Additional Destination #3:

Fax Number

E-Mail Address

Destination Date (mm-dd-yyyy) of Arrival

Purpose of Visit

Type of Visit (Select One)
Extended Stay
Indefinite Stay

Destination Date (mm-dd-yyyy) of Departure (If Any)

Frequent Visit
One-Time Visit
Destination Information:

Destination Type (Select One)
Home

Hotel

School

Other

Address Line 1
Address Line 2
City

Foreign State or Province

Country

Postal Code

Phone Number

Fax Number

E-Mail Address

If there are any additional destinations, please attach the required information on a separate sheet of paper.

DS-4024

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