Name of Applicant (Last, First & Middle) Date of Birth (mm/dd/yyyy) EPSTEIN, JEFFREY EDWARD 01/20/1953 12. Height 43. Hair Color 14. Eye Color } 45. Occupation 16. Employer or School (applicable) sft. i1in. GRAY BLUE BANKER SOUTHERN TRUST COMPANY 17. Additional Contact Phone Numbers Home Cell Work 18. Permanent Address: /f P.O. Box is listed under Mailing Address or i residence is different from Mailing Address. StreetfRFD # 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: Street/RFD # or P.O. Box Apartment/Unit DARREN INDYKE 2 KEAN COURT City State Zip Code Phone Number Relationship LIVINGSTON NI 07039 PY ATTORNEY 20. Travel Plans iy 7 j Departure Date (mm/dd/yyyy) Return Date (mm/dd/yyyy) Countries to be visited STOP! YOU HAVE COMPLETED YOUR APPLICATION BE SURE TO SIGN AND DATE PAGE ONE * DS 82B 2 B 08 2013 2* DS-82 08-2013 Page 2 of 2 EFTA00314147