USINFO.PL. U.S. Citizen Registration Form

U.S. Citizen Registration Form

American Embassy Warsaw, Poland

To register successfully, please fill in all the fields marked by an asterisk "* "

* Last Name:
* First & Middle Name:
* Date of Birth
Place of Birth (City, State, Country):
* U.S. Passport Number:
* Date & Place of Issue:
* Expiration Date:
Social Security Number:

If accompanied by family members who are not registered separately, please give the name, date and place of birth, Social Security Number (optional), and passport number, date and place of issue of each individual:
Expected Date of Arrival in Poland:
Type of Stay:	Tourist Business Permanent
* Expected Date of Departure from Poland:

* Address in Poland:
* Telephone (Home):
Telephone (Work):
Telephone (Mobile):
Fax:
E-mail:

* Emergency Contact: (name, address, relationship, phone):
Would you like to be a Warden?	» Read here about the Warden System
	Yes No
I would like to receive information from the Embassy in:
	English Polish
Do you authorize the Embassy to give your address and phone number to the Warden for your Region?
	Yes No