ࡱ> 7 "cbjbjUU 7|7|{Gl43333Z4x 6J?J?J?J?J?HFJ TlVlVlVl=l0q0v$y {bw)LJ?J?LLwZVJ?J?@xZVZVZVLJ?J?TlZVLTlZV6ZV]]J?v6  1Y23NZ]]Vx0x]|PF|]ZV INSTRUCTIONS FOR COMPLETING REQUEST FOR FOREIGN NATIONAL UNCLASSIFIED VISIT OR ASSIGNMENT Note: Unclassified visits/assignments to privately owned facilities are not arranged by the U.S. Department of Energy. If your schedule is changed, postponed, or canceled after this form is submitted, please contact your embassy or the office arranging to visit promptly. ______________________________________________________________________________________________________________ GENERAL INFORMATION ______________________________________________________________________________________________________________ l. Purpose This form is designed to be used by foreign nationals in arranging unclassified visits/assignments to the U.S. Department of Energy (DOE) and its contractor operated facilities. 2. Who Must Submit This form must be completed by foreign nationals or someone acting on his/her behalf in arranging unclassified visits/assignments to DOE and its contractor operated facilities. 3. Where to Submit Send a completed Form IA-473 to one of the following offices or organizations: -The laboratory or facility you wish to visit or be assigned; -The appropriate program office or Office of International Affairs at the Department of Energy Headquarters in Washington, D.C. The form may be submitted to the American Embassy in your country. If you have any questions concerning this form, call (202) 586-9211. ______________________________________________________________________________________________________________ GENERAL INSTRUCTIONS ______________________________________________________________________________________________________________ l. Complete all items by typewriter in English. For Non-Programmatic visits, the following questions must be completed: 1, 5, 7, 10, 13, 16, 17, 18, 19, 20,26, 27, 28, 29, 32, 35, 38, 39, 40, 41, and 42. 2. The * * blocks in the form are reserved for the Host to add special data and codes. 3. The unshaded check boxes must contain an entry. Valid entries are AY@=Yes, AN@=No, AX@=Selection. ______________________________________________________________________________________________________________ SPECIFIC INSTRUCTIONS ______________________________________________________________________________________________________________ Part 1 Personal Data Item No. Instruction 1 Enter from the passport the full name of person for whom the visit/assignment is being requested. If no middle name, enter AMMM@. Use capital letters for this response. 2 Visitor Number is a unique number assigned by the computer system to identify individual visitors or assignees. The number is transcribed to the form by the data entry operator. 3 Request Number is a sequential number maintained for each facility by the computer system. The number transcribed to the form by the Data Entry Operator. 4 Check the appropriate box. 5 Enter the visitor=s birth place, the city and country. 6 Enter visitor=s date of birth. 7 Enter name of the visitor=s country of current citizenship. 8 Enter the visitor=s passport number. 9 Enter the expiration date of the visitor=s passport. 10 If you are a currently an immigrant alien, enter a AY@ in the box. An immigrant alien included permanent resident aliens, temporary resident aliens (i.e. under amnesty), refugees, and asylees. Other foreign nationals including those authorized to work in the U.S., businessmen, students, tourists, exchange visitors, and non-immigrants, enter an AN@ in the box. 11 Enter a AY@ in the box if an interpreter will be needed. This does not mean that an interpreter will be provided. When feasible, the most will arrange for an interpreter. 12 Enter at least one of the three telephone numbers requested. Indicate which type of number is provided. 13 Enter the name and address of the visitor=s current employer. State/Province are mandatory for U.S. and Canada only. 14 If different from 13, enter the name and address of the visitor=s current place of work. State/Province are mandatory for U.S. and Canada only. 15 Enter the visitor=s work title, position or a short description of duties. Part II Visit/assignment Specification data This section is divided into parts IIA, and IIB. Part IIA is used to report general information about the proposed visits or assignment. Part Iib is used to report detailed information for an assignment to one DOE facility. Use the addendum to request visits to more than one facility. A separate question block is completed for each facility visited. Item No. Instructions 16 Enter the date this request is submitted. 17 Check the box that describes the purpose of this request. 18 Enter AY@ in the box if the visitor is currently in the United States, otherwise enter d@N@. 19 Indicate if the visitor will require an Exchange Visitor (J-1) Visa. To obtain the J-1 Visa, the foreign national must be issued a Form IAP-66, ACertificate of Eligibility for Exchange Visitor (J-1) Status,@ the Responsible Officer registered with he U.S. Information Agency (USIA) for the particular program question. 20 Enter AY@ if the assignment involves periodic (intermittent) visits. 21 Enter the name of the international agreement in any, under which this visit/assignment is sponsored. Enter AN/A@ if no agreement. 22 Enter the name of DOE person, if any contacted in conjunction with this request. 23 Enter the name of the DOE organization for the person contacted in 21. 24 Enter the telephone number of the DOE person contacted. 25 Enter the Name of the organization providing the financial support for this visit/assignment. Financial support includes salary, per diem, and travel. 26 Enter the amount of financial support in U.S. dollars. 27 Enter the Name and Location (City, State) of the facility to be visited. If more facilities will be visited under this request, complete the addendum with the appropriate information. 28 Enter proposed start and end dates for visits or assignment. Space is provided for multiple visits to the same facility. The Host will enter the Facility Code, whether the facility is a Security and;/or Sensitive Facility, and if applicable, the Division within the facility to be visited. 29, 30, 31 These entries will be completed by the Host. 32, 33, 34 29 Enter the Name of the Host for this visit/assignment. 30 Enter the Telephone number of the designated Host. 31 Enter the Identification of the Buildings and rooms to be accessed by the visitor or assignee. This is a free form response and is saved in the system exactly as entered. 32 Enter, the total number of work days the visitor will be on site. Total days for multiple visits. 33 If this is a Programmatic visit/assignment, enter AY@ in the box; otherwise, enter AN@ Non-Programmatic visits/assignments cover repairmen, cafeteria workers, delivery men, and personnel making no direct contribution to an energy program. 34 Enter the Subject Codes that categorize the technologies to be discussed or worked on. 35 Describe in detail, particularly for multi--site visits what subjects may be discussed. Furnish sufficient information to establish your interest clearly. This will enable laboratory personnel to prepare adequately for your visit. Part III Visit and Assignment Program Information and Remarks Part III is completed by the DOE Headquarters program office, field office, or laboratory having responsibility for the program involved and desiring the visit/assignment be approved. Insure that the visitor (or his/her) agent) has provided sufficient information in Parts * and ** to allow proper evaluation of the request. If not, obtain the required information prior to submission to the request for processing. Item No. Instructions 36 Enter AY@ in box if this is a high level or protocol visit, otherwise enter AN@. 37 Enter the cost that will be incurred by DOE or its contractors in supporting this visit/assignment. 38 Enter the B&R (Budget and Reporting) Code that identifies the DOE funding for this visit/assignment, 39 Enter the DOE organizational code for the HDE Associate Director for the applicable program. Enter AN/A@ for non-technical visits or assignments. 40 Enter the appropriate Visit/Assignment Purpose Code from the Purpose Table. 41 This item is extremely important in the approval process, particularly if the visit/assignment involves a sensitive subject, a security area at a sensitive facility, and/or a sensitive country. Include reference to applicable international agreement(s) , if any. 42.43 Enter the name and title of the official or contractor initiating this require. 44 Signature of the official or contractor initiating the requires.\ 45 Date official or contractor signed the request. 46,47 Enter name and title of the local approving official 48 Signature of local approving official. 49 Date local approving official signed the request. 50 Enter remarks about approval/disapproval, limitations concerning the visit, special security conditions., type of computer access, and any other remarks that will support arrangements for the visit/assignment or provide information for future program management. Part IV Miscellaneous information that may be required for processing the visit/assignment request. Item No. Instructions 51 Enter the type of Visa used to enter the U.S. 52 Enter the Expiration date of your Visa. 53 Enter a description of the type of business for the visitor;=s current employer. 54 Enter the visitor=s technical qualifications, which are applicable to the visit/assignment. Include, a description of university/college training and degrees conferred. 55 Enter the visitor=s field of research; if none, enter ANONE@. 56 For assignments only, enter name, citizenship, date of birth, city and country of birth, and relationship to the visitor of all family members who will accompany the visitor or join his/her at a later date. If more than four family members, enter the same information for each additional family member in the remarks section. U.S. DEPARTMENT OF ENERGY Office of International Affairs REQUEST FOR FOREIGN NATIONAL UNCLASSIFIED VISIT OR ASSIGNMENT PRIVACY ACT STATEMENT - Collection of the information is authorized pursuant to the Atomic Energy Act of 1954, as amended, 42 U.S.C. 2011, and the Department of Energy Organization Act, Pub. L. No. 95-91. The primary purpose of the requested information is to determine unclassified access to facilities operated by the Department of Energy (DOE) or its contractors. Access to the information collected many be provided to appropriate Federal agencies for law enforcement purposes. Collection of the information is mandatory. Failure to provide the information may result in denial of access to DOE or contractor facilities. BURDEN DISCLOSURE STATEMENT - Public reporting burden for this collection of information is estimated to average 3.5 ours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to U.S. Department of Energy, Office of Information and Resources Policy, Plans and Oversight, Paperwork Reduction Project (1910-2100), 1000 Independence Avenue, S.W., Room F-318/GTN, AD-241.2, Washington, D.C. 20585, and to the Office of Management and Budget (OMB), Paperwork Reduction Project (1910-2100), Washington, D.C. 20503. ___________________________________________________________________________________________________________ PART 1 PERSONAL DATA 1. Name of visitor (Family, Given, Middle)2. Visitor Number*3. Request Number * FORMTEXT       FORMTEXT       FORMTEXT      4. Gender of Visitor5. Place of Birth (City, Country)6. Date of Birth (DD-MM-YY) Male  FORMCHECKBOX  Female  FORMCHECKBOX  FORMTEXT       FORMTEXT   - FORMTEXT   - FORMTEXT   7. Country of Citizenship8. Passport Number9. Expiration Date (DD-MM-YY) FORMTEXT       FORMTEXT       FORMTEXT   - FORMTEXT   - FORMTEXT   10. Immigrant Alien11. Interpreter Needed?12. Work Telephone and/or Telex No. Or Fax. No. Yes  FORMCHECKBOX  No  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX (Enter type and number) FORMTEXT      13. Name and Address of Current Employer14. Name and Address of Place of Work (if different from 13)Name:  FORMTEXT      Name:  FORMTEXT      Street:  FORMTEXT      Street:  FORMTEXT      City:  FORMTEXT      State/Province:  FORMTEXT      City:  FORMTEXT      State/Province:  FORMTEXT      Zip Code:  FORMTEXT      Division:  FORMTEXT      Zip Code:  FORMTEXT      Division:  FORMTEXT      Country:  FORMTEXT      Country:  FORMTEXT      15. Title, Position, or Description of Visitor=s or Assignee=s Duties FORMTEXT      PART II VISIT/ASSIGNMENT DATA16. Date of Request (DD-MM-YY)17. This request is for (Check appropriate box)18. Visitor currently in U.S. FORMTEXT   - FORMTEXT   - FORMTEXT    Visit  FORMCHECKBOX  Assignment  FORMCHECKBOX  Assignment Extension  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX 19. (For assignment only) Will you require an20. (For assignment only) is the assignment for intermittent periods? Exchange Visitor (J-1) visa? Yes  FORMCHECKBOX  No  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX 21. Identify specific international Agreement, if any FORMTEXT      22. Name of DOE Contact23. DOE Contact Organization FORMTEXT       FORMTEXT      24. DOE Contact Telephone Number25. Name of Financial Sponsor26. Cost (Sponsor other than DOE) FORMTEXT       FORMTEXT       FORMTEXT      PART IIB VISIT/ASSIGNMENT FACILITY INFORMATION27. Facility of Organization to be Visited/AssignedCodeSecurity Sensitive Division28. Desired Dates (DD-MM-YY) Name:  FORMTEXT      Yes  FORMCHECKBOX  Yes  FORMCHECKBOX   Start  FORMTEXT   - FORMTEXT   - FORMTEXT    End  FORMTEXT   - FORMTEXT   - FORMTEXT   No  FORMCHECKBOX  No  FORMCHECKBOX  Location:  FORMTEXT      29. Name of Host responsible for the Visit/Assignment30. Host=s Telephone Number FORMTEXT       FORMTEXT      31. Building and Room Numbers FORMTEXT      32. Number of days on Site33. Programmatic Visit/Assignment34. Subject Codes FORMTEXT       Yes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT      35. Subjects to be discussed or statement of research in which you wish to be assigned. FORMTEXT       (Sensitive subject) Yes  FORMCHECKBOX  No  FORMCHECKBOX  Name of Visitor:  FORMTEXT      Request Number:  FORMTEXT      PART III VISIT/ASSIGNMENT PROGRAM INFORMATION AND REMARKS36. High Level/Protocol Visit?37. Cost (DOE)38. B&R Code39. HDE Assoc. Director=s Code40. Visit or Assignment Yes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT       Purpose Code *  FORMTEXT      41. Purpose and Justification of Visit/Assignment, including benefits to DOE program(s) *  FORMTEXT       *  FORMTEXT       *  FORMTEXT       *  FORMTEXT      42. Name of Requesting Official or Contractor43. Title and Organization of Requesting Officer*  FORMTEXT      **  FORMTEXT      44. Signature of Requesting Official or Contractor45. Date Signed (DD-MM-YY) FORMTEXT   - FORMTEXT   - FORMTEXT   46. & 47. Name & Title of Local/Headquarters Approving Official48. Signature of Local Approving Official49. Date Signed (DD-MM-YY) FORMTEXT       FORMTEXT   - FORMTEXT   - FORMTEXT    FORMTEXT      50. Remarks *  FORMTEXT       *  FORMTEXT      PART IV MISCELLANEOUS INFORMATION (MANDATORY FOR DOE SPONSORED V/A=S, AND IAP-66 APPLICATIONS)51. Type of Visa52. Expiration Date of Visa (DD-MM-YY) FORMTEXT       FORMTEXT   - FORMTEXT   - FORMTEXT   53. Kind of Business or Organization of Assignee=s Employer (e.g. government, company, laboratory, university)  FORMTEXT      54. Educational background (Include university/college training with degrees and dates conferred) FORMTEXT      55. Field of Research FORMTEXT      56. 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