Emergency Contact & Information Form for Visitors to Ethiopia

Please complete and return to ECCO immediately upon arrival or complete online and SUBMIT.
Name of Registrant: Surname First Name Middle Name
Permanent Address:
Street City Province
Postal Code
Passport information:
Passport Number Ethiopia Visa Number
Country of Passport (contains Ethiopian visa) Type
Passport Expiry Date Visa Expiry Date
Country of Birth .
Citizenship .
Date of Birth .
Expected date of departure from Ethiopia .
Contact Information (authorized contact such as a doctor who knows your medical history)

Name:
 Surname First Name
Address:
Street    City     Province
Postal Code Telephone

Emergency Contact (next of kin)
Name:
 Surname First Name
Address:
Street    City     Province
Postal Code Telephone
Family members accompanying registrant
Surname First Name
Date of birth Passport No. Citizenship
Relationship to Registrant

I have read the notice below and agree to its conditions.

________________________________________
Signature

________________
Date

This information may be used by the Ethiopia-Canada Cooperation Office, the Canadian Embassy or third parties that the ECCO may deem appropriate, for the protection and well-being of myself and my family, including evacuation in case of emergency.

The information contained on this form will be used only to contact, protect and/or assist me and family members who are traveling with me.

Please give this form to the driver or the ECCO receptionist/client service officer or click the Submit button.

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