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pdf*OMB APPROVAL NO. 1405-xxxx
EXPIRATION DATE:
ESTIMATED BURDEN:
U.S. Department of State
REQUEST FOR ESCORT SCREENING COURTESIES
Processing and coordination require that submissions be made at least three (3) business days prior to initial departure
date. Please e-mail completed forms to [email protected]. Please direct questions to OFM at
202-647-4554 or 202-736-4311/4123.
Date of Request
Passport Nationality
month/day/year
month/day/year
(Example: January 30, 2004)
Passport Number
Full Name of Traveler
Official Title
Country of Birth
Date of Birth
month/day/year
(Example: January 30, 2004)
City of Birth
Point of Contact**
Organization
Telephone and Fax Numbers
Phone
Extension
Fax
After Hours Telephone Number(s)
E-mail Address for Confirmation
**The name of the Mission's point of contact must appear on the form or the request will not be processed.
Flight Itinerary
If traveling from or to DC or NY,
choose Airport from dropdown list
(click on the"Airport" box); otherwise,
please type name of Airport in
shaded box.
Airline and Flight Number
Enter time as:
Hour : Minute
00 : 00
month/day/year
Departure Airport
Arrival Airport
Airline and Flight Number
month/day/year
Departure Airport
month/day/year
month/day/year
Departure Airport
month/day/year
Arrival Airport
Itinerary continues on next page
DS-4138
02-2010
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pm
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pm
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month/day/year
Arrival Airport
Airline and Flight Number
Time
Yes
Time
Time
Time
Time
No
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Full Name of Traveler
Official Title
Nationality
Flight Itinerary Continuation
If traveling from or to DC or NY,
choose Airport from dropdown list
(click on the"Airport" box); otherwise,
please type name of Airport in
shaded box.
Airline and Flight Number
Departure Airport
Arrival Airport
Airline and Flight Number
Departure Airport
Arrival Airport
Airline and Flight Number
Departure Airport
Arrival Airport
Airline and Flight Number
Airline and Flight Number
Hour : Minute
00 : 00
month/day/year
am
pm
am
pm
am
pm
am
pm
am
pm
am
pm
am
pm
am
pm
am
pm
am
pm
am
pm
month/day/year
month/day/year
Arrival Airport
Arrival Airport
pm
month/day/year
month/day/year
Departure Airport
am
month/day/year
month/day/year
Departure Airport
Time
month/day/year
Departure Airport
Arrival Airport
Airline and Flight Number
Enter time as:
month/day/year
month/day/year
month/day/year
month/day/year
Privacy Act and Paperwork Reduction Statement
*AUTHORITIES: State - DHS/TSA Memorandum of Agreement (July 22, 2009), Foreign Missions Act of 1982 (22 U.S.C. 4301-4316) as amended.
PURPOSE: The information solicited on this form will be used by the U.S. Department of State (DOS) to adjudicate requests for the assignment of DOS representatives to
escort eligible senior officials of foreign governments through the airport security screening process.
ROUTINE USES: The information provided on this form may be provided to other federal agencies for law enforcement, administrative or other statutorily authorized
purposes. This information also may be provided to the employing foreign government or international organization.
Disclosure: Submission of information is voluntary; however, failure to provide any of the requested information may result in the denial of the requested service.
*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 documentation, providing the information and/or documents required, and reviewing the final collection. You do not have to supply this information
unless this collection displays a currently valid OMB control number. If you have comments on the accuracy of this burden estimate and/or recommendations for reducing
it, please send them to: A/GIS/DIR, Room 2400 SA-22, U.S. Department of State, Washington, DC 20522-2202.
DS-4138
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| File Type | application/pdf |
| File Title | DS4138.far |
| Author | delaneykt |
| File Modified | 2010-02-12 |
| File Created | 2010-02-12 |