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Fillable Printable Form DS-4024

Fillable Printable Form DS-4024

Form DS-4024

Form DS-4024

GenderEmail Address
Full Name (Last, First, Middle)
Date of Birth (mm-dd-yyyy)Citizenship
SMART TRAVELER ENROLLMENT PROGRAM
Emergency Contact Information: Fill out your Emergency Contact Information. Your Emergency Contact should be someone who is not traveling or
living with you.
The Smart Traveler Enrollment Program is a free service provided by the U.S. Government to U.S. nationals who are traveling to, or living in, a foreign
country. Enrollment 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 enroll your trip or foreign residence, please fill out the form below and return to the U.S. Department of State.
Page 1 of 3
Personal Information: Fill out your Personal Information
Address CityU.S. State or Foreign Province
CountryPostal CodePhone Number
Email Address
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: Bureau of Consular Affairs, Overseas Citizens
Services (CA/OCS/PMO), U.S. Department of State, SA-17, 10th Floor, Washington, DC 20036.
U.S. Department of State
DS-4024
04-2016
OMB APPROVAL NO. 1405-0152
EXPIRATION DATE: 04/30/2019
ESTIMATED BURDEN: 20 Minutes
U.S. Passport Information
Passport or Passport Card Number
Full Name (Last, First, Middle)
Relationship to Primary Traveler/Resident
PAPERWORK REDUCTION ACT
PRIVACY ACT STATEMENT
Fill out your Privacy Act information. You must check the check box to indicate that you have read the Privacy Act Statement.
AUTHORITY: The information solicited on this form is requested pursuant to provisions in 22 U.S.C. § 2715 and 22 U.S.C. § 4802(b) of the U.S.
Code and 22 C.F.R. § 71.1 and 22 C.F.R. § 71.6 of the Code of Federal Regulations.
PURPOSE: To notify U.S. nationals in the event of a disaster, emergency or other crisis, and for evacuation coordination.
ROUTINE USES: 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. nationals, or for law enforcement and administration
purposes or pursuant to court order. The information is also made available to private U.S. nationals, known as wardens, designated by U.S.
embassies to assist in communicating with the American community in an emergency. More information on the Routine Uses for the system can be
found in System of Records Notice, State-05, Overseas Citizens Services Records.
DISCLOSURE: Providing the information requested on this form is purely voluntary. Failure to provide the requested information on the form could
make it more difficult for the Department to notify the U.S. national respondent in the event of an emergency.
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
I have read the terms of the Privacy Act Notice.
FriendsMediaLegal RepresentativeMedical RepresentativeMembers of CongressOther
Waiver Comments
Please use this space below to specify individuals, explain, or clarify your response or describe your selection of "Other".
Page 2 of 3DS-4024
Destination
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, Date of Arrival at Destination, Date of Departure from Destination (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.
Date of Arrival (mm-dd-yyyy)Date of Departure from Destination (mm-dd-yyyy)Purpose of Visit
My departure date is
unknown or indefinite
Address CityU.S. State or Foreign Province
CountryPhone NumberEmail AddressPostal Code
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
Address CityU.S. State or Foreign Province
Full Name (Last, First, Middle)
CountryPhone NumberEmail AddressPostal Code
Date of Birth (mm-dd-yyyy)CitizenshipRelationship to Primary Traveler/Resident
CommentsPassport or Passport Card Number
Additional Traveler/Member of Household #2
Address CityU.S. State or Foreign Province
Full Name (Last, First, Middle)
CountryPhone NumberEmail AddressPostal Code
Date of Birth (mm-dd-yyyy)CitizenshipRelationship to Primary Traveler/Resident
CommentsPassport or Passport Card Number
Additional Traveler/Member of Household #3
Address CityU.S. State or Foreign Province
Full Name (Last, First, Middle)
CountryPhone NumberEmail AddressPostal Code
Date of Birth (mm-dd-yyyy)CitizenshipRelationship to Primary Traveler/Resident
CommentsPassport or Passport Card Number
DS-4024Page 3 of 3
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.
Date of Arrival (mm-dd-yyyy)Date of Departure from Destination (mm-dd-yyyy)Purpose of Visit
My departure date is
unknown or indefinite
Address CityU.S. State or Foreign Province
CountryPhone NumberEmail AddressPostal Code
Additional Destination #1
Date of Arrival (mm-dd-yyyy)Date of Departure from Destination (mm-dd-yyyy)Purpose of Visit
My departure date is
unknown or indefinite
Address CityU.S. State or Foreign Province
CountryPhone NumberEmail AddressPostal Code
Additional Destination #2
Date of Arrival (mm-dd-yyyy)Date of Departure from Destination (mm-dd-yyyy)Purpose of Visit
My departure date is
unknown or indefinite
Address CityU.S. State or Foreign Province
CountryPhone NumberEmail AddressPostal Code
Additional Destination #3
If there are any additional destinations, please attach the required information on a separate sheet of paper.
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