1-_Midway_Atoll_NWR_Travel_Request_Form_Fillable.pdf

Arrival Date (to Midway) (mm/dd/yyyy)

Departure Date (from Midway) (mm/dd/yyyy)

First Name (As it appears on passport)

Last Name (As it appears on passport)

Middle Name (Spell out if done so on your passport)

Billing Address (Street or PO Box)

City

State

Zip

Home Phone

Work or Cell Phone

E-mail Address

Company or Affiliation

Date of Birth (mm/dd/yyyy)

Body Weight (lbs)

Male or Female?

Passport Country of issue

Passport Number

Passport Expiration (mm/dd/yyyy)

Travel Visa Number

Travel Visa Expiration (mm/dd/yyyy)

Permanent Resident Card Number

Are you part of the Visa Waiver Program?

Address while in Honolulu (foreign passports only):

Number of Bags

Total Baggage Weight (50lb max per passenger)

Emergency Contact Name

Emergency Contact Phone

Emergency Contact E-mail

Emergency Contact Relationship

Emergency/Air Evac Insurance company/policy # (if required)

If not already arranged, do you request lodging on

Midway Atoll?

If "yes" to above, do you request a single room or double room?

If in a double room, name of person sharing (required)?

Do you request a bicycle or other transportation rental?

Please list any medical expertise or training (e.g. MD, RN, EMT, etc.) (optional)

Midway Atoll National Wildlife Refuge/Battle of Midway National Memorial Travel Request Form

List any special accommodation requests for FWS consideration.

Travel Dates:

Passenger Information:

Passport Information (current and valid required):

Non-US Citizen Information:

Luggage Information:

Emergency Contact Information:

Billeting & Transportation Information:

*** Please ensure all information is accurate. Inaccurate information could delay or prevent your departure. ***

Revised 10/27/2014