Non-Citizen Data Form.doc

United States Department of Agriculture

Non-Citizen Worker Data Sheet

___ New

(Please print or type; enter n/a where applicable)

___ Change

Section I, (FAS required) tc \l1 "Section I, (FAS required) _________________________________________________________________________ __________ Family name

First name Middle name Male/female

Date of birth: Month Day Year Place of birth (city and country) Citizen of

Legal permanent resident of

Position at home

USDA facility _____________________________________________________________

Street address _____________________________________________________________

City _________________________ State _______________ ZIP Code ___________

Visit funded by ______________________________________Amount (US dollars) _______________

Subject of study _______________________________________________________________________

Expected arrival date _____/_____/_____ Expected departure date _____/_____/_____

Month Day Year

Immediate family members accompanying the Worker: Yes __ No __ If yes, complete the following:

First & last name

Date of birth Place of birth

Relationship

Section II. (Visa/Passport Information) tc \l1 "Section II. (Visa/Passport Information) Actual arrival date _____/_____/_____

Actual departure date _____/_____/_____

Reason for visit _______________________________________________________________________

Worker institution or company name ______________________________________________________

Address _____________________________________________________________________________

Phone # ________________ Fax # ________________ E-mail __________________________

Visa type _____ Visa expiration date ______/_____/_____ Visa authorized by ___________________

Green card # ________________ Passport # ____________________ Country of issue _____________

Passport expiration date ______/_____/_____

SS# ____________________

Section III. ( Location Information) tc \l1 "Section III. ( Location Information) I-94 # _________________________ Expiration date ______/_____/_____

Date of entry to US ______/_____/_____

Port of entry ____________________________

Home address ________________________________________________________________________

Home phone # _______________________

E-mail_________________________________

Residence addresses in other countries during the past 5 years __________________________________

US residence address __________________________________________________________________

US home phone # _____________ Business phone # _____________ E-mail ____________________

Host=s name _____________________________________

Host=s address ________________________________________________________________________

Host=s phone number ______________ E-mail address ________________________________

Section IV. ( Changes in Visa Information) tc \l1 "Section IV. ( Changes in Visa Information) Name change to __________________________________

Home address change to ____________________________________________

Visa-type changed to __________

Effective date _____/_____/_____

Expiration date _____/_____/_____

Transfer to ___________________________________________________________________________

Effective date _____/_____/_____

Expiration date _____/_____/_____

Other _______________________________________________________________________________

Extension of visa (reason): ______________________________________________________________

Current visa expiration date _____/_____/_____ Extend to _____/_____/_____