A00001_-_Att1_-_Incoming_Foreign_National_Visitors_Form.docx

HAIBP RFP Amendment A00001 - Attachment 1:

Incoming Foreign National Visitors Form Incoming Foreign National Visitors

Please provide the requested information for each incoming Foreign National visitor no later than thirty (30) business days prior to the actual visit. Email the completed form to DNDO.Security@hq.dhs.gov, Contracting Officer, Jennifer D’Addio at Jennifer.DAddio@HQ.DHS.GOV, Contract Specialist, Ryan Buck at Ryan.Buck@hq.dhs.gov, and DNDOHAIBPIndustryDay@hq.dhs.gov by April 2, 2018, by 12:00 PM, EST.

Last Name:

First & Middle Name:

Place of Birth & Date of Birth:

Gender:

Height:

Weight:

Passport number:

Date Passport Issued:

Passport Expiration date:

Country of Citizenship:

Country of Residence:

Company/Agency/University:

How Long with Company/Agency/University:

Title:

Phone Number:

Email Address:

Purpose of Visit: Participate in Helium-3 Alternative Implementation Program (HAIBP) Oral Presentation.

POC (or PM) name and phone number: Karin Clarkson, 202-254-7556 Date(s) of visit: Between April 30 – May 9, 2018

(NOTE: Identify specific programs and spell out acronyms.)

PRIVACY ACT NOTICE

Authority: Executive Order 12977, “Interagency Security Committee,” and Interagency Security Committee Standard, “Physical Security Criteria for Federal Facilities” authorizes the collection of this information.

Purpose: DHS will use this information to vet foreign nationals to determine if access may be granted to a DHS facility or program.

Routine Uses: The information will be used by and disclosed to DHS personnel, contractor employees, or other agents who require the information to determine if access to a DHS facility or program should be granted. DHS may also share the information with other government agencies as necessary to determine if adverse information exists on the individual seeking access to a DHS facility or program.

Disclosure: Furnishing this information (including your Passport information) is voluntary; however, failure to furnish the requested information may delay or prevent your requested access to a DHS facility or program.