Attachment 4 NF-0037.4-SEC-VisitorBackGround Check.pdf

Date: NBAF Sponsor Name:

Date of Visit:

(Y/N)

Country Of Origin

Company or

Agency

Date of Birth (mm/dd/yyyy)

Driver's License

Issue State

Driver License or

Passport Expiration

Telephone Number

FOR PC:

FOR MAC:

NBAF FORM 37 (JULY 2022) NF-0037.4-SEC-VisitorBackgroundCheck

Driver License Or

U.S. Passport Number

PRIVACY ACT STATEMENT

The Privacy Act, 552a, requires that federal agencies inform individuals, at the time information is solicited from them, whether the disclosure is mandatory or voluntary, by what authority such information is solicited, and what uses will be made of the information. The collection of this information is authorized by EO 9397, 6 USC 341, 44 USC 3101, and EO 12958. Provision of the information concerning foreign visits is mandatory under the provisions of EO 12958. Failure to provide it may impact planned visits. Use of this information is for internal purposes to facilitate visitor processing.

Controlled// SP-SPII When filled out, this document contains sensitive information exempt from mandatory disclosure under the Freedom of Information act, 5 U.S.C. 552 (b)(2). Do not release without prior approval by USDA.

Social Security Number

TYPE ONLY in the table below (handwritten forms will NOT be accepted)

Once completed please e-mail this document to: NBAFSecurity@usda.gov For your personal security, please DO NOT send personally identifiable information (the information contained within this document) to any other e-mail address. You should password protect and encrypt this form when returning it to NBAF and send the password in a separate email.

To password protect this document, follow the instructions below:

Select File tab, then select Protect Using Password; select Viewing; create a Password; reenter the Password to verify, and click on Apply.

Select File tab, then select Export, and click on Encrypt; create a Password; reenter the Password to verify, then click Save.

For your personal security this form will be destroyed immediately upon completion of access request process.

For questions or concerns, please contact NBAF Security at (785) 712- 3093

US

Cit izen

Name (Last, First, Middle)

CUI //SP-SPII

VISITOR BACKGROUND CHECK

For all Background Checks, allow 3 working days for processing prior to visitor arrival

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