To be completed at least once annually.
Spouse's Name (if applicable)
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US Address (if applicable)
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Phone (including area code)
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( ) - |
City, Postal Code, Country
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Phone (including country code)
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Date of Birth
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Spouse's Date of Birth
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Birthplace
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Spouse's Birthplace
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Citizenship
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Spouse's Citizenship
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Spouse's Passport #
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Expiration
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Please send copies of the first page of your (and your family members') passport(s) for our records if you have not already done so.
(U. S.) D. L. #
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State
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Type
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(International) D. L. #
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Country
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Insurance
Do you have medical and/or other insurance that will cover you outside the U.S., and does your "Personal Administrator" have all necessary information regarding this? Yes________ No_________
For our records, please indicate your current provider and policy number.
Personal Administrator
Phone (including area code)
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( ) - |
Power of Attorney (if different from above)
Phone (including area code)
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( ) - |
Emergency Contact
Phone (including area code)
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( ) - |
(Form updated 2/7/2008)