EFTA00314147.pdf

Name of Applicant (Last. First 8 Middle) Date of Birth (mn✓ddyyyyy) EPSTEIN, JEFFREY EDWARD 01/20/1953 12. Height 13. Hair Color 14. Eye Color 15. Occupation 16. Employer or School (if applicable) sit. ilia. GRAY BLUE BANKER SOUTHERN TRUST COMPANY 17. Additional Contact Phone Numbers Homo CO Homo CNI Wrt vat 18. Permanent Address: If P.O. Box is listed under Mailing Address ff i residence is afferent from Meiling Address. Street/RFD a or URB (No P.O. Box) APartment/Unrt City State Zip Code 19. Emergency Contact - Provkle the inlormzeion ofa person not beveling with you to be contacted in the event of en emergency. Name Address Street/RFD I or P.O. Box Apartment/Unit DARREN I NDYKE 2 KEAN COURT City State Zip Code Phone Number Relationship L /VI NGSTON NJ 07039 ATTORNEY 20. Travel Plans Departure Date (narsrddlyyyy) Return Date (mrn/disbyyyy) Countries to be visited STOP! YOU HAVE COMPLETED YOUR APPLICATION BE SURE TO SIGN AND DATE PAGE ONE • DS 82 B OS 201, 2 • DS-82 08-2013 Page 2 of 2 EFTA00314147