Name of Applicant (Last, First & Middle) Date of Birth (mm/dd/yyyy) EPSTEIN, JEFFREY EDWARD 01/20/1953 12. Height 13. Hair Color 14. Eye Color 16. Employer or School (if applicable) Sft. 11in. GRAY BLUE SOUTHERN TRUST COMPANY 47. Additional Contact Phone Numbers ; Horner Cel Work 48. Permanent Address: if P.O. Box is listed under Mailing Address or if residence is different from Mailing Address. StreetRFD # or URB (No P.O. Box) City 19. Emergency Contact - Provide the information of a person not traveling with you to be contacted in the event of an emergency. Name Address: Stree/RFD # or P.O. Box Apartment/Unit DARREN INDYKE 2 KEAN COURT City State Zip Code Relationship LIVINGSTON NJ 07039 ATTORNEY 20. Travel Plans , a her tha ‘eg Departure Date (mmidd/yyyy) Retum Date (mm/dd/yyyy) Countries to be visited STOP! YOU HAVE COMPLETED YOUR APPLICATION BE SURE TO SIGN AND DATE PAGE ONE * DS 82 B 08 2013 2* DS-82 08-2013 Page 2 of 2 EFTA00314128