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 City U.S. State or Foreign Province
Country Postal Code Phone 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.
Friends Media Legal Representative Medical Representative Members of Congress Other
Waiver Comments
Please use this space below to specify individuals, explain, or clarify your response or describe your selection of "Other".
