Foreign_National_Visitor_Form.doc
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- Solicitation number
- 70B02C19R00000013
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A0002 - Attachment 2 - Foreign National Visitor Request Form
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DEPARTMENT OF HOMELAND SECURITY
FOREIGN NATIONAL VISITOR ACCESS REQUEST
INSTRUCTIONS
In order to support visits by foreign nationals to DHS facilities and personnel, visitor hosts shall submit this form to DHS element Foreign Visit representatives (per element Foreign Visit Procedures) 30 days in advance of a visit (30 days or less) or 60 days in advance of an assignment (31 days or more).
For purposes of this form, a foreign national is defined as a person who is not a citizen or national of the United States. This form shall be filled out for each visitor (including drivers, interpreters, etc.) and each program to be visited. Visitor hosts shall be notified upon approval or disapproval of the visit. If the visit may involve sharing or disclosure of classified information, the host must contact the DHS Foreign Disclosure Officer prior to the visit for guidance.
Please return this form with a scanned copy of the visitor’s biographic passport page.
FOREIGN VISITOR INFORMATION
NAME OF VISITOR (LAST, FIRST, MIDDLE)
GENDE
DATE OF BIRTH (MM-DD-YY)
CITY AND COUNTRY OF BIRTH
COUNTRY(IES) OF CITIZENSHIP
GREEN CARD
GREEN CARD EXPIRATION DATE (MM-DD-YY)
LAWFUL PERMANENT RESIDENT NUMBER
| SOCIAL SECURITY NUMBER |
| VISA TYPE |
VISA NUMBER
VISA EXPIRATION DATE (MM-DD-YY)
PASSPORT COUNTRY OF ISSUE
PASSPORT NUMBER
PASSPORT EXPIRATION DATE (MM-DD-YY)
CURRENT EMPLOYER / DIVISION / OFFICE
TYPE OF BUSINESS/ORGANIZATION
EMPLOYER ADDRESS (STREET, CITY, STATE, ZIP CODE, COUNTRY)
EMPLOYER PHONE NUMBER
VISITOR JOB TITLE / POSITION
VISITOR CONTACT NUMBER
VISITOR CONTACT NUMBER WHILE IN UNITED STATES
VISITOR EMAIL ADDRESS
VISIT INFORMATION
DATE OF REQUEST
DHS VISITOR HOST NAME
Neil Lanzendorf
HOST ORGANIZATION (ELEMENT,DIVISION,OFFICE)
US Customs and Border Protection Air and Marine Operations
HOST PHONE NUMBER
202-325-3642
HOST E-MAIL ADDRESS
neil.c.lanzendorf@cbp.dhs.gov
HOST FAX
VISIT START DATE
July 8, 2019
VISIT END DATE
July 12, 2019
NUMBER OF DAYS ON SITE
UNCLASSIFIED DESCRIPTION OF VISIT PURPOSE / SUBJECTS TO BE DISCUSSED / INTERNATIONAL AGREEMENTS
Oral presentation for the P3 Aircraft Maintenance and Logistics solicitation
FULL NAME OF ORGANIZATION AND PROGRAM TO BE VISITED
US Customs and Border Protection Procurement Directorate
FACILITIES TO BE VISITED (INCLUDE BUILDING NAME/NUMBER, ADDRESS, ROOM NUMBERS, AND HIGHEST LEVEL OF CLASSIFICATION FOR WHICH THE FACILITY IS ACCREDITED – UNCLASSIFIED, SECRET, SCI,) 1331 Pennsylvania Ave NW, Washington DC 20229 National Place, Suite 1355, Conference Room 1308
Accredited - Unclassified
REMARKS (COORDINATION / SPECIAL REQUIREMENTS)
REVIEWS
| FOREIGN VISIT COORDINATOR |
| DATE |
PHONE
FAX
| COMMENTS |
| INTERNAL SECURITY REP |
| DATE |
| PHONE |
| FAX |
| COMMENTS |
| APPROVAL AUTHORITY |
| DATE |
| PHONE |
| FAX |
| COMMENTS |
OTHER REVIEWER
| DATE |
| PHONE |
| FAX |
| COMMENTS |
OTHER REVIEWER
| DATE |
| PHONE |
| FAX |
| COMMENTS |
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.
DHS Form 11052-1 (07/05)
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_1621941720.unknown
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