Travel Companion Form - Dgs Pass

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Travel Companion Form
(revised 9/12/2013)
Important: This form must be submitted to the DGS Business Process Department, Department 937, ATG, in
order to receive pass privileges with Delta Air Lines. Incomplete forms will be returned to you.
1 – Employee Information
PPR Number:
Always complete this section in its entirety
Last Name
First Name
Middle Initial
Today’s Date
Social Security No.
Department/Station
Hire Date
Important: Travel Companions are not eligible for medical/dental benefits. The purpose of this form is to
designate a travel companion for pass privileges only. If you are married, you may have spouse pass privileges or
companion pass privileges but not both at the same time. Married employees who designate a travel companion
will lose spouse pass privileges until the employee revokes his/her travel companion designation and redesignates
his/her spouse as eligible for spouse pass privileges. This can only be done effective as of the employee’s pass
anniversary date. The parents of single employees (with or without children) who designate a travel companion will
not be eligible for Transoceanic flight days (without service charge).
Form must be received by DGS Pass Bureau 2 weeks prior to pass anniversary date.
2 – Action Needed
CHECK ONE and COMPLETE ALL SECTIONS
Add New Travel Companion
Is this Travel Companion currently receiving pass privileges as a nondependent or parent?
YES
NO
A travel companion may be designated once every pass anniversary year. If this is a change of travel
companion, the change will not be effective until your next pass anniversary date.
Correct Travel Companion Personal Information
Report Death of Travel Companion
Date of Death: _
_
Reinstate Spouse Pass Privileges?
YES
NO
If adding a new companion, please complete a separate Travel Companion Information Update Form
Revoke Travel Companion and add spouse
Marriage Date: _
_
DGS Employee Information & Update Form must be completed in addition to this form.
Revoke Travel Companion
Please specify Revoke Date:
_
_
Reinstate Spouse Pass Privileges on next pass anniversary date?
YES
NO
If you wish to designate a companion for your next pass anniversary year, you must complete a separate Travel
Companion Information Update Form and submit it prior to your next pass anniversary date.
3 – Travel Companion’s Personal Information
- COMPLETE THIS SECTION
Last Name
First Name
Middle Initial
Gender
Male
Female
Address
City
State
Zip
Date of Birth:
Identification Number
Social Security (Required):
Home Phone:
Government ID:
Cell Phone:
Passport # and Country:
Business Phone:
CHOOSE ONE- Relationship to employee:
Relative
Friend
Other (explain below)

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