Traveler Certification Form

Black Travelers International – Traveler Certification

(Required under 31 CFR §515, Cuban Assets Control Regulations)
Traveler Name:*
Passport Number:*
Trip Dates:*

MonthDayYear
Date
I certify that my travel to Cuba falls under the following authorized category(check one):*

Support for the Cuban PeopleEducational Activities (people-to-people exchanges, group educational programs)Professional Research and Professional MeetingsReligious ActivitiesPublic Performances, Clinics, Workshops, Exhibitions, or Athletic CompetitionsHumanitarian ProjectsJournalistic ActivityFamily VisitsOfficial Government Business
Other (please specify, consistent with OFAC rules):
Traveler Statement:
I confirm that my travel to Cuba is consistent with the category selected above and will comply with U.S. law. I understand that knowingly providing false information may subject me to penalties under U.S. law.
Traveler Signature:*

Clear
Date:*

MonthDayYear
Date
Should be Empty:

Black Travelers International – Traveler Certification