Monday-Friday: 8:00am-5:00pm
210 South Main Street   Goshen, IN 46526
(800) 635-0963  /  (574) 534-1521




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First TravelerSecond Traveler
Last Name* Last Name
First Name* First Name

Street Address* Street Address
City* City
State* State
Zip Code* Zip Code
Country Country

Primary Phone* Primary Phone
Other Phone Other Phone
Other Phone Other Phone
Email Email

Birthplace (City and State) Birthplace (City and State)
Birthplace (Country) Birthplace (Country)
Date of Birth Date of Birth
Citizenship Citizenship
Gender: Gender:

ID you will carry when traveling: ID you will carry when traveling:
Where ID was issued (State & Country) Where ID was issued (State & Country)
Name exactly as it appears on ID Name exactly as it appears on ID
ID number ID number
ID date of issue ID date of issue
ID date of expiration ID date of expiration

TSA PreCheck or Global Entry number TSA PreCheck or Global Entry number
DHS Redress Number DHS Redress Number

Emergency Contact Name Emergency Contact Name
Emergency Contact Phone Number Emergency Contact Phone Number

Will you be celebrating a special occasion? Please specify the date and nature of the celebration:
Special Occasion (date and description) Special Occasion (date and description)
Do you have any special dietary needs?
Special Dietary Needs Special Dietary Needs
Do you have any mobility issues or health concerns we should be aware of?
Mobility or Health Concerns Mobility or Health Concerns

Monday-Friday: 8:00am-5:00pm
210 South Main Street   Goshen, IN 46526
(800) 635-0963  Fax: (574) 534-2158