Print and take a copy of this form with you on your trip. Also leave a copy at home with a friend or relative.

Personal Information
Full name
Nickname
Home address
Home phone
Mobile or cellular phone
Home fax
Home e-mail address
Birthday (MM/DD/YYYY)
SSN
Passport number
Driver’s license number
Business Information
Company
Business address
Job title
Business phone
Business fax
Business e-mail address
Manager’s name and phone
Assistant’s name and phone
Web page address
Emergency and Medical Information
In case of emergency, contact
Emergency contact’s address
Emergency contact’s phone
Doctor’s name
Doctor’s phone
Doctor’s address
Medical insurance carrier and member number
Blood type

Known medical conditions
Known allergies
Current medications
Airline Information	Flight #1	Flight #2	Flight #3	Flight #4
Date
Airline
Airline phone number
Flight number
Departure city
Departure time
Destination city
Arrival time
Car Rental Information
Pick-up date
Company
Company phone number
Confirmation number
Quoted rental rate
Pick-up location
Drop-off location
Drop-off date
Hotel Itinerary
Date	Hotel	City, Country	Reservation confirmation number	Phone number

Credit Cards and Travelers Checks
Credit card type	Issuing bank	Credit card number	Phone number
Traveler’s check type	Value	Check number	Phone number