Following are step-by-step instructions to fill out the Form DS-4138, Request for Escort Screening Courtesies .
Once completed please print, scan, and email Form DS-4138 to escortscreening@state.gov
1. Date of Request (The form contains drop-down boxes for the month, day, and year)
The date the request is submitted to the Office of Foreign Missions.
2. Passport Nationality
The issuing country on the traveler’s passport.
3. Passport Number
The passport number of the traveler’s passport.
4. Full Name of Traveler
The full name of the traveler as shown on the passport with the surname or family name in capital letters. (example: John SMITH)
5. Official Title
The official title of the traveler requesting Airport Escort Screening Courtesies.
6. Date of Birth
The date of birth of the traveler. (example: January 30, 1965)
7. Country of Birth
The traveler’s country of birth.
8. City of Birth
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 (embassy, mission, etc.).
11. Telephone and Fax Numbers
The POC’s business hour telephone and fax numbers.
12. After Hours Telephone Number (s)
The POC’s after-hours phone number(s).
13. E-Mail Address for Confirmation
The e-mail address where the confirmation and future communications may be sent.
14. Airline and Flight No.
The traveler’s airline and flight number (example: Delta Airlines – DL 498).
15. Departure Airport
The airport the traveler is leaving.
16. Arrival Airport
The airport destination of the traveler.
17. Month/Day/Year (This form contains drop down boxes for the month, day, and year)
The departure and arrival dates.
18. Time
The departure and arrival flight times: Hour: Minute (example 08:23) and check AM or PM.
19. Itinerary Continues on Next Page
Check yes or no.
(content revision date 03/12/2013)
