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 


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