Form Ds-3072 - Repatriation / Emergency Medical And Dietary Assistance Loan Application - U.s. Department Of State

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U.S. Department of State
OMB APPROVAL NO. 1405-0150
EXPIRATION DATE: 06/30/2017
ESTIMATED BURDEN: 20 MINUTES
REPATRIATION / EMERGENCY MEDICAL AND DIETARY ASSISTANCE LOAN APPLICATION
PART 1 - APPLICATION TO BE COMPLETED BY EACH ADULT APPLICANT REGARDLESS OF NATIONALITY
1. Last Name
(Print Clearly)
2. First Name
3. Middle Name
4. Social Security Number
5. Date of Birth
6. Place of Birth
7. Identity Document
8. Sex
(mm-dd-yyyy)
Issuing Country
Male
Passport No.
Female
OR
National ID No.
9. Current lodging where you may be contacted now .
10. Phone number where you may be contacted now.
11. E-mail address where you may be contacted now.
12. Medical condition, current injuries, or limited mobility relevant to evacuation.
13. Verifiable Billing Address at Final Destination in United States or other Permanent Address (Not a Post Office Box)
14. Address Line 1
15. Address Line 2
18. Country
16. City
17. State/Province
19. Postal Code
20. Telephone Number(Include Country/City Codes)
21. E-mail Address
22. Emergency Contact (Do not list someone traveling with you)
24. First Name
23. Last Name (Print Clearly)
25. Address Line 1
26. Address Line 2
27. City
28. State/Province
29. Country
30. Postal Code
31. Telephone Number
(Include Country/City Codes)
32. E-mail Address
33. Relationship to you
34. Minor Children or Incapacitated/Incompetent Adults to be Repatriated or to Receive Emergency Medical and Dietary Assistance, list below.
Check here if none
(Print Clearly)
35. Last Name
36. First Name
37. Middle Name
38. Social Security
39. Date of Birth
40. Place of Birth
41. Identity Document
42. Sex
43. This Person is My
Number
(mm-dd-yyyy)
Issuing Country
Male
Passport No.
OR
Female
National ID No.
44. Last Name
(Print Clearly)
45. First Name
46. Middle Name
47. Social Security
48. Date of Birth
49. Place of Birth
50. Identity Document
51. Sex
52. This Person is My
Number
(mm-dd-yyyy)
Issuing Country
Male
Passport No.
Female
OR
National ID No.
DS-3072
Page 1 of 3
06-2015

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