Name of Applicant (Last, First & Middle) Date of Birth (mmdd/yyyy) EPSTEIN, JEFFREY EDWARD 01/20/1953 "46. Employer or Schoo! (i applicable) sft. iain. GRAY BLUE SOUTHERN TRUST COMPANY 12. Height 13. Hair Color 14, Eye Color 17. Additional Contact Phone Numbers Home: Cell Work 18. Permanent Address: /f P.O. Box is listed under Mailing Address orf residence is different from Mailing Address. StreeRFD # or URB (No P.O. Box) City 19. Emergency Contact - Provide the information of a person not traveling with you to be Gontadlad in the evant of an emergency, Name Address: Street/RFD # or P.O. Box ApartmenvUnit DARREN INDYKE 2 KEAN COURT City State Zip Code Phone Number Relationship LIVINGSTON No 07039 862-485-6315 20. Travel Plans Departure Date (mm/dd/yyyy) Retumn Date (mnvdd/yyyy) Countries to be visited STOP! YOU HAVE COMPLETED YOUR APPLICATION BE SURE TO SIGN AND DATE PAGE ONE * DS 82 B 08 20132 * DS-82 08-2013 Pane 2 of 2 EFTA00314139