**U.S. CITIZEN REGISTRATION FORM -- U.S. EMBASSY BEIRUT**

**NAME:** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
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> (Last Name) (First Name) (Middle Name) (Sex)

**Date of Birth** \_\_\_\_\_\_\_ \_\_\_\_\_\_ \_\_\_\_\_\_\_\_ **Place
of Birth** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ **Marital
Status**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> (Month) (Day) (Year) (City-Country) (Sing/Mar/other)

**U.S. Place of Date of Date of**

**Passport \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Issue**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ **Issue**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_ **Expiration \_\_\_\_**\_\_\_\_\_\_\_\_\_\_

(Number) (City/Country) (Mon./Day/Yr) (Mon/Day/Yr)

**Your U.S. Address** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Street Address) (City or Town) (State & Zip code)

**Your Local Address**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Street Address) (City or Village) (Local Telephone No.)

**Occupation** (Check one of the following) **Intended Length of Stay**

\_\_\_\_\_\_ Businessman \_\_\_\_\_ Permanent
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_ Student \_\_\_\_ for \_\_\_\_year(s) (Local Fax Number)

\_\_\_\_\_\_ Educator \_\_\_\_\_for \_\_\_\_month(s)

\_\_\_\_\_\_ Dependent \_\_\_\_\_Indefinite
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_ other (Specify: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_Unknown (Social Security Number)

**Date of Entry to Lebanon
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**\_ **E-mail Address**:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Emergency Contact**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_

(Name of Person here or in U.S., to be notified in emergency)
(Relationship) (Telephone No.)

**Address**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Building/Street Address) (City or Town) (State & Zip code)

**[Accompanying Immediate Family Members (spouse,
children):]{.underline}**

**NAME DATE/PLACE OF BIRTH CITIZENSHIP**

> **(IF APPLICABLE, U.S. PASSPORT NUMBER)**

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**[PRIVACY ACT RELEASE FORM]{.underline}**

Under the provisions of the Privacy Act of 1974 (public law 93 - 578),
no information may be released from U.S. government files without the
prior written consent of the individual in question. Understanding my
rights under the Privacy Act of 1974, I hereby authorize the American
Embassy at Beirut, Lebanon, and the Department of State to release
information from my file to the following individuals and/or
organization:

1\. FAMILY MEMBERS YES \_\_\_\_\_ NO \_\_\_\_\_

2\. FRIENDS YES \_\_\_\_\_ NO \_\_\_\_\_

3\. LEGAL REPRESEMTATIVE YES \_\_\_\_\_ NO \_\_\_\_\_

4\. MEDIA YES \_\_\_\_\_ NO \_\_\_\_\_

5\. MEDICAL REPRESENTATIVE YES \_\_\_\_\_ NO \_\_\_\_\_

6\. MEMBER OF CONGRESS YES \_\_\_\_\_ NO \_\_\_\_\_

7\. Specific Individuals only:

NAME:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Relationship\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Address & Telephone
no.\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

NAME
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Relationship\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Address & Telephone
no.\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

NAME
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Relationship\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Address & Telephone
no.\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

REGISTERING CITIZEN\'S SIGNATURE
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
DATE: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**If you are interested in receiving warden messages, please send** an
**e-mail to: <join-wardenmessagebeirut@mh.databack.com>.**

**You may unsubscribe at any time.** **Further information may be
obtained at http:// lebanon.usembassy.gov**