Download:
pdf |
pdfU.S. Department of State
OMB APPROVAL NO. 1405-0152
EXPIRATION DATE:
ESTIMATED BURDEN: 20 Minutes
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 upcoming 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
Full Name (Last, First, Middle)
Mailing Address
City
Country
Postal Code
U.S. State or Foreign Province
Phone Number
Date of Birth (mm-dd-yyyy) Citizenship
Marital Status
Fax Number
Email Address
Gender
Occupation
U.S. Passport Information:
Passport Number
Passport Card Number
Passport/Passport Card Date of
Issue (mm-dd-yyyy)
OR:
Passport/Passport Card Date of
Expiration (mm-dd-yyyy)
Emergency Contact Information: Fill out your Emergency Contact Information. Your Emergency Contact should be someone who is not traveling or
living with you.
Full Name (Last, First, Middle)
Mailing Address
Country
City
Postal Code
Phone Number
U.S. State or Foreign Province
Fax Number
Email Address
Relationship to Primary Traveler/Resident
Business Information: If you have a seperate business address, please fill in your contact information.
Full Name (Last, First, Middle)
Country
DS-4024
XX-XXXX
U.S. State or Foreign Province
City
Mailing Address
Postal Code
Phone Number
Fax Number
Email Address
Page 1 of 5
PAPERWORK REDUCTION ACT
Public reporting burden for this collection of information is estimated to average 20 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: A/GIS/DIR, Room 2400, SA-2, U.S. Department of State, Washington, DC 20522-2202
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, 22 U.S.C. § 4802(b), 22 C.F.R. § 71.1 and 22 C.F.R. § 71.6.
PURPOSE: To notify U.S. citizens in the event of a disaster, emergency or other crisis, 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.
I have read the terms of the Privacy Act Notice.
I do not authorize the U.S. Department of State to disclose my information to anyone except as authorized by law.
OR
I agree to allow the U.S. Department of State to disclose my information to:
Family Members
Friends
Legal Representative
Media
Medical Representative
Members of Congress
Other
Waiver Comments Please use this space below to specify individuals, explain, or clarify your response or describe your selection of
"Other"
DS-4024
Page 2 of 5
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.
Date of Arrival At Destination (mm-dd-yyyy)
Type of Visit (Select One)
Purpose of Visit
Extended Stay
Indefinite Stay
Date of Departure from Destination (mm-dd-yyyy) (If any)
Frequent Visit
One-Time Visit
Destination Type (Select One)
Destination Information:
Home
Mailing Address
Hotel
School
Other
City
Country
Postal Code
Foreign State or Province
Phone Number
Fax Number
Email 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
Full Name (Last, First, Middle)
City
Mailing Address
Postal Code
Country
U.S. State or Foreign Province
Phone Number
Date of Birth (mm-dd-yyyy) Citizenship
Fax Number
Email Address
Relationship to Primary Traveler/Resident
Comments
U.S. Passport Number
U.S. Passport Card Number
OR:
Passport/Passport Card Date of
Issue (mm-dd-yyyy)
Passport/Passport Card Date of
Expiration (mm-dd-yyyy)
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
Full Name (Last, First, Middle)
Mailing Address
U.S. State or Foreign Province
City
Country
Postal Code
Phone Number
Date of Birth (mm-dd-yyyy) Citizenship
Fax Number
Email Address
Relationship to Primary Traveler/Resident
Comments
U.S. Passport Number
U.S. Passport Card Number
OR:
DS-4024
Passport/Passport Card Date of
Issue (mm-dd-yyyy)
Passport/Pasport Card Date of
Expiration (mm-dd-yyyy)
Page 3 of 5
Additional Traveler/Member of Household #3
Full Name (Last, First, Middle)
Mailing Address
Country
City
Postal Code
U.S. State or Foreign Province
Phone Number
Date of Birth (mm-dd-yyyy) Citizenship
Email Address
Fax Number
Relationship to Primary Traveler/Resident
Comments
U.S. Passport Number
U.S. Passport Card Number
OR:
Passport/Passport Card Date of
Issue (mm-dd-yyyy)
Passport/Passport Card Date of
Expiration (mm-dd-yyyy)
If there are any additional destinations, please attach the required information on a separate sheet of paper.
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:
Date of Arrival at Destination (mm-dd-yyyy)
Purpose of Visit
Type of Visit (Select One)
Extended Stay
Indefinite Stay
Date of Departure from Destination (mm-dd-yyyy) (If any)
Frequent Visit
One-Time Visit
Destination Information:
Destination Type (Select One)
Home
Hotel
Mailing Address
Country
School
Other
Foreign State or Province
City
Phone Number
Postal Code
Fax Number
Email Address
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:
Purpose of Visit
Date of Arrival at Destination (mm-dd-yyyy)
Type of Visit (Select One)
Extended Stay
Indefinite Stay
Date of Departure from Destination (mm-dd-yyyy) (If any)
Frequent Visit
One-Time Visit
Destination Information:
Destination Type (Select One)
Home
DS-4024
School
Other
City
Mailing Address
Country
Hotel
Postal Code
Phone Number
Foreign State or Province
Fax Number
Email Address
Page 4 of 5
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 #3:
Date of Arrival at Destination (mm-dd-yyyy)
Purpose of Visit
Type of Visit (Select One)
Extended Stay
Indefinite Stay
Date of Departure from Destination (mm-dd-yyyy) (If any)
Frequent Visit
One-Time Visit
Destination Information:
Destination Type (Select One)
Home
Mailing Address
Country
Hotel
School
Other
Foreign State or Province
City
Postal Code
Phone Number
Fax Number
Email Address
If there are any additional destinations, please attach the required information on a separate sheet of paper.
DS-4024
Page 5 of 5
| File Type | application/pdf |
| File Title | DS4024.far |
| Author | RiversDA |
| File Modified | 2009-07-30 |
| File Created | 2009-07-30 |