The following information explains how a foreign mission should complete Form DS-4138, Request for Escort Screening Courtesies .
Please note that once completed, this form must be printed, electronically scanned, and sent by electronic mail to escortscreening@state.gov.
1. Date of Request (The form contains drop-down boxes for the month, day, and year)
This should be the date that request will be submitted to the Office of Foreign Missions.
2. Passport Nationality
This should be the issuing country of the traveler’s passport.
3. Passport Number
This should be the passport number listed on the traveler’s current passport from the country mentioned in step 2.
4. Full Name of Traveler
This line should contain the full name of the traveler with the surname or family name in capital letters. (example: John SMITH)
5. Official Title
This should be the official title of the traveler requesting Airport Escort Screening Courtesies.
6. Date of Birth
This should be the date of birth of the traveler. (example: January 30, 1965)
7. Country of Birth
This should be the traveler’s country of birth.
8. City of Birth
This should be the name of the city in which the traveler was born.
9. Point of Contact
The Point-of-Contact (POC) should be someone who is available to receive calls during business and non-business hours from the assigned escort officer.
10. Organization
The POC’s organization should be listed here.
11. Telephone and Fax Numbers
These are the business hour telephone and fax numbers for the POC.
12. After Hours Telephone Number (s)
This telephone number should be an after-hours phone number for the POC.
13. E-Mail Address for Confirmation
This should be an e-mail for the approval/denial to be sent to.
14. Airline and Flight No.
This should be the traveler’s airline (example: Delta Airlines – DL 498) and flight number.
15. Departure Airport
This should be the airport for which a departure is taking place.
16. Arrival Airport
This should be the arrival airport for the departing flight.
17. Month/Day/Year (This form contains drop down boxes for the month, day, and year)
This should be the date information for both the departure and arrival portions of the trip.
18. Time
The times of the departure and arrival flights should be entered in the following format: Hour: Minute 00:00. The box for either am or pm should also be checked.
19. Itinerary Continues on Next Page
Check either yes or no if the request will continue onto a second page.
