Name:   

Phone:  

Fax:      

Relevant data about traveler including travel dates per itinerary:

Type of National Passport:  

U.S. State of Residence:          City:  

U.S. Immigrations Status (Please check one or fill in the following)

Holds green card                            Holds valid H,J or L class visa

Holds valid B class visa                 Other:  

Itinerary:

Departure Date (mm/dd/yy)

          Length of stay       Country to be visited               Purpose of visit to each country

                                                                                           Business     Tourism      Transit

How would you like your response:    Phone     Fax     E-Mail

E-Mail Address

Most responses will be within 24 hr. Should your request take longer, we will advise you via fax or phone.