Date *

Email *

Name *

Current Assignment Address (International) *

Actual Residence in U.S. while on furlough *

Phone Number *

Driver's License #--DOB--State of Issue *

Spouse Name *

Driver's License #--DOB--State of Issue *

Total # of people in your party *

Age of children *

Names of children 21 or older who may need to drive vehicle *

DL#--DOB *

Approximate time period vehicle will be needed (dd/mm/yy thru dd/mm/yy) *

Geographical Itinerary: Approximate Anticipated Mileage *

Point of Entry in U.S. *

Driving Record (Accidents or tickets in last 3 years) Husband,Wife,Children *

Will you have other Transportation *

If yes, explain *

Mission Board under which you are serving *

Length Of Service *

Are You Returning To Field *