Name of Applicant (Last. First 8 Middle)

Name of Applicant (Last. First 8 Middle) EPSTEIN, JEFFREY EDWARD Date of Birth (mn✓ddyyyyy) 01/20/1953 12. Height 13. Hair Color sit. ilia. GRAY 17. Additional Contact Phone Numbers Homo CO Wrt 18. Permanent Address: If P.O. Box is listed under Mailing Address ff i residence is afferent from Meiling Address. Street/RFD a or URB (No P.O. Box) APartment/Unrt 14. Eye Color BLUE 15. Occupation 16. Employer or School (if applicable) BANKER SOUTHERN TRUST COMPANY Homo CNI vat City State Zip Code 19. Emergency Contact - Provkle the inlormzeion of a person not beveling with you to be contacted in the event of en emergency. Name Address Street/RFD I or P.O. Box Apartment/Unit DARREN I NDYKE 2 KEAN COURT City State Zip Code Phone Number Relationship L /VI NGSTON NJ 07039 ATTORNEY 20. Travel Plans Departure Date (narsrddlyyyy) Return Date (mrn/disbyyyy) Countries to be visited STOP! YOU HAVE COMPLETED YOUR APPLICATION BE SURE TO SIGN AND DATE PAGE ONE • DS 82 B OS 201, 2 • DS-82 08-2013 Page 2 of 2 EFTA00314147