PBCC Tour Information 2018 Question Title 1. First Name, exactly as it appears on passport. Please type in ALL CAPS. If you do not have a passport yet, please enter your name exactly as you will/have entered it on the passport application. Question Title 2. Middle Name or Initial, exactly as it appears on passport (or blank if none on passport. Again, ALL CAPS. Question Title 3. Last Name, exactly as on passport. Again, ALL CAPS. Question Title 4. Passport Number Question Title 5. Date of Issue of Passport Date / Time Date Question Title 6. Expiration Date of Passport Date / Time Date Question Title 7. Place of Birth (as listed on passport) Question Title 8. Place where passport was issued (most U.S. passports say "United States Department of State" Question Title 9. Date of Birth Date / Time Date Question Title 10. Nationality (as listed on passport) Question Title 11. Other credential information (for those who do not have a US Passport, enter your greencard or other information here) Name as appears exactly on greencard or other card Number Issue Date Expiration Date Question Title 12. Home Address: Street Question Title 13. City Question Title 14. State Question Title 15. Zip Code Question Title 16. E-mail Question Title 17. Emergency Contact Name Question Title 18. Emergency Contact Relationship Question Title 19. Emergency Contact Phone Number Question Title 20. Emergency Contact E-mail Question Title 21. Select the pet animal allergies you have (for home-stay purposes) Dog Cat Bird All animals with fur NONE Other (please specify) Question Title 22. Do you have asthma or any problems with smoke (for home-stay and hotel purposes) Yes No Question Title 23. Food allergy or restrictions. Select the food(s) you cannot eat. All animal meat ("I'm a vegetarian") All animal meat or products ("I'm a vegan") Pork All shellfish Peanuts Tree Nuts Eggs Milk/milk products (lactose intolerant) Milk/milk products (dairy allergy) Soy I CAN EAT ANYTHING! Other (please specify) Question Title 24. Food allergy comments. Please comment below if any of your answers above require explanation Question Title 25. Other allergies (pollen, penicillin, etc.). You will also be filling out a more complete medical fact sheet later, but we need general allergy information at this point. SUBMIT