Attachment 4c-DHS-Form-11055 (1).pdf

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DHS FORM 11055 (06/17)

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INSTRUCTIONS

Requestors shall forward this form to the foreign national(s) being considered for screening. One form may include multiple individuals for the same visit or event by clicking the Add Individual button. Once the foreign national completes the Foreign National Information section, return the form to the Requestor. All fields are mandatory. Failure to complete all the fields may result in a processing delay.

FOREIGN NATIONAL INFORMATION

LAST NAME:

FIRST NAME:

MIDDLE NAME:

ALIASES:

VISITOR TYPE:

GENDER:

DATE OF BIRTH (MM/DD/YYYY):

CITY AND COUNTRY OF ORIGIN:

DUAL CITIZENSHIP:

LEGAL PERMANENT RESIDENT:

COUNTRY(IES) OF CITIZENSHIP:

CITY AND COUNTRY OF RESIDENCE:

PASSPORT COUNTRY OF ISSUE:

PASSPORT NUMBER:

EXPIRATION DATE (MM/DD/YYYY):

VISA ISSUANCE LOCATION:

VISA TYPE:

VISA NUMBER:

VISA EXPIRATION DATE (MM/DD/YYYY):

ALIEN REGISTRATION NUMBER (LPR):

CURRENT EMPLOYER (COUNTRY OR COMPANY):

EMPLOYER TELEPHONE NUMBER:

GOVERNMENT OWNED BUSINESS:

CURRENT EMPLOYER (COUNTRY OR COMPANY ADDRESS (STREET, CITY, STATE, ZIP CODE, COUNTRY)):

TYPE OF BUSINESS OR ORGANIZATION:

JOB TITLE OR POSITION:

CONTACT NUMBER:

EMAIL ADDRESS:

SPONSOR INFORMATION (For Internal Use Only)

NAME (LAST, FIRST, MIDDLE):

JOB TITLE OR POSITION:

DATE OF REQUEST (MM/DD/YYYY):

COMPONENT:

OFFICE OR PROGRAM:

EMAIL ADDRESS:

TELEPHONE NUMBER:

VISIT OR EVENT INFORMATION (For Internal Use Only)

TYPE OF VISIT/EVENT:

AFFECTED PROGRAM:

DATE(S) OF VISIT OR EVENT:

CLASSIFICATION OF ACCESS:

DISCLOSURE OF INFORMATION:

NAME AND TITLE OF VISIT HOST OR AFFECTED FEDERAL EMPLOYEE:

HOST ORGANIZATION:

PURPOSE OF REQUEST:

HOST TELEPHONE NUMBER:

LOCATION OF ACCESS:

HOST EMAIL ADDRESS:

BACKGROUND (DESCRIBE THE CIRCUMSTANCES SURROUNDING THE SCREENING REQUEST)

PRIVACY ACT STATEMENT

Authority: The collection of this information is authorized by 6 U.S.C. § 341 (2010); Security Executive Agent (SecEA) Directive (SEAD) 3; DHS Policy Directive 121-11, Foreign Access Management; and DHS MD 11052, Internal Security Program.

Purpose: DHS will use this form to screen a foreign national and determine if he or she should be granted access to DHS information, personnel, systems, and facilities.

Routine Uses: The information will be used by and disclosed to DHS Security personnel, contractor employees, or other agents responsible for evaluating foreign nationals who request access to DHS. DHS may share the information when appropriate and permissible under a routine use in the DHS/ALL/PIA-048(a) Foreign Access Management System (FAMS) and the DHS/ALL-024 Department of Homeland Security Facility and Perimeter Access Control and Visitor Management System of Records Notice, 75 FR 5609 (February 3, 2010).

Disclosure: Providing the requested information is voluntary, but failure to do so could result in the denial of the foreign national’s access to DHS information, personnel, systems, and facilities.

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