Official Goverment 0 Diplomatic Date of Issue:__ / / Day Manta Year Date of Expiry:__ / _ _ / Day Month Year Issuing Authority: 0 US Department of State D Other: HEALTH AND TRAVEL INSURANCE: Have you purchased travel insurance for your trip? O No °Yes. insurance company name:_____ _ _ _ Name

ial Goverment 0 Diplomatic Date of Issue:____ / _ / Date of Expiry: / _ _ / _ _ Day Manta Year Day Month Yew Issuing Authority: 0 US Department of State 0 Other: HEALTH AND TRAVEL INSURANCE: Have you purchased travel insurance for your trip? O No O Yes, insurance company name:___ _ _ Name of H

l Goverment 0 Diplomatic Date of Issue:____ / _ / Date of Expiry: / _ _ / _ _ Day Month Year Day Month Year Issuing Authority: 0 US Department of State 0 Other: HEALTH AND TRAVEL INSURANCE: Have you purchased travel insurance for your trip? O No O Yes, insurance company name:___ _ _ _ Name o

ssport. if applicable. • If you previously have been issued a second valid (2 yea) passport, you must include this passport book for submission to US Department of State. II you have been issued a second yard passport Co more than one occasion, include the second valid passport issued most recently. • It you previo

l Goverment 0 Diplomatic Date of Issue:____ / _ / Date of Expiry: / _ _ / _ _ Day Month Year Day Month Year Issuing Authority: 0 US Department of State 0 Other: HEALTH AND TRAVEL INSURANCE: Have you purchased travel insurance for your trip? O No O Yes, insurance company name:___ _ _ _ Name o

edether dcosnent Y. It naunera/Passport rails 469911707 12. Aare sawaws I Cote of ssue 217 0 5 2 1 0 1 1 0 10. 101 staameievilssung &minty US Department of State der moan Year U. Tapia. atanata/Valid oral 11- /gee imaszveNminxe or issue USA 216 015 2 1 0 2 I 0 day mional 14. Mac cranara HMO eficape

om my iPhone On Dec 16, 2010, at 2:30 PM, "Bella Klein" e > wrote: is in the office and she is asking for 2 checks for her international passport: US Department of State — for S170 and TRAVISA - for $199. Please advise . Thank you, Bella EFTA_R1_00208388 EFTA01830228

alidity) passport, if =pplicable. If you previously =ave been issued a second valid passport, you must include this passport =ook for submission to US Department of State. If you have been issued a second valid =assport on more than one occasion, include the second valid passport issued most recently. If you previous