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NAME IN FULL II. FAMILY NAME GIVEN NAME AND MIDDLE INITIAL NATIONALITY AND PASSPORT NUMBER ACTION BY CBP NOTE IF ADDITIONAL SPACE IS REQUIRED ATTACH LIST IN TRIPLICATE. REASON FOR REQUEST IV. ARRANGEMENTS FOR DEPARTURE FROM THE U.S. OF THE LISTED CREWMEN AND DATE AND PORT OF DEPARTURE AIR CARRIER AND FLIGHT NUMBER OR VESSEL. MAILING ADDRESS OF CARRIER SIGNATURE TITLE FOR GOVERNMENT USE ONLY COPY GRANTED OFFICE DATE DENIED MAILED DELIVERED CBP For......

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