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.
Enter time as:
Hour : Minute
 00 : 00
Point of Contact**
E-mail Address for Confirmation
U.S. Department of State
REQUEST FOR AIRPORT 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 ESCORTSCREENING@STATE.GOV. Please direct questions to the Office of
the Chief of Protocol at 202-647-4503.
Date of Request
month/day/year
(Example: January 30, 2004)
Passport Nationality
Passport Number
Full Name of Traveler
Official Title
Date of Birth
month/day/year
month/day/year
(Example: January 30, 2004)
Country of Birth
City of Birth
Organization
Telephone and Fax Numbers
After Hours Telephone Number(s)
Phone
Extension
FAX
Flight Itinerary
Airline and Flight Number
Departure Airport
Arrival Airport
month/day/year
month/day/year
Time
am
pm
am
pm
Departure Airport
Arrival Airport
month/day/year
month/day/year
am
pm
Departure Airport
Arrival Airport
month/day/year
month/day/year
am
pm
am
pm
am
pm
Airline and Flight Number
Airline and Flight Number
**The name of the Mission's point of contact must appear on the form or the request will not be processed.
Itinerary continues on next page
Yes No
DS-4138
07-2017
Page 1 of 2
*OMB APPROVAL NO. 1405-0105
EXPIRATION DATE: 05-31-2021
ESTIMATED BURDEN: 10 MIN.
Enter time as:
Hour : Minute
 00 : 00
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.
Full Name of Traveler
Official Title
Nationality
Flight Itinerary Continuation
Airline and Flight Number Departure Airport
Arrival Airport
month/day/year
month/day/year
Time
am
pm
am
pm
Departure Airport
Arrival Airport
month/day/year
month/day/year
am
pm
am
pm
Airline and Flight Number
Airline and Flight Number
Departure Airport
Arrival Airport
month/day/year
month/day/year
am
pm
am
pm
Airline and Flight Number Departure Airport
Arrival Airport
month/day/year
month/day/year
am
pm
am
pm
Airline and Flight Number
Departure Airport
Arrival Airport
month/day/year
month/day/year
am
pm
am
pm
Airline and Flight Number Departure Airport
Arrival Airport
month/day/year
month/day/year
am
pm
am pm
Page 2 of 2
DS-4138
Privacy Act and Paperwork Reduction Statement
*AUTHORITIES: The information is sought pursuant to the 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 Department of State 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 as covered under STATE 36, Security Records. This information also may be provided to the employing foreign government or international organization.
DISCLOSURE: Providing this information is voluntary; Failure to provide the information requested on this form may result in denial of airport escort screening.
*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: Office of the Chief of Protocol, Dept. of State, 2201 C St. NW, Suite 1238, Washington, DC 20520
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