21._Attachment_E_-_Foreign_National_Data_Card.pdf

Attachment E

Sterling Breaker Replacement WAPA Form 3000-72 Foreign National Data Card

DE-SOL-0008721

10 August 2015

INSTRUCTIONS FOR PREPARING Foreign National Data Card for Unclassified Foreign Visits and Assignments to WAPA (WAPA F 3000-72#- 03-06)

Routing of Form:

1. Requestor- Meeting host initiates the form at least 30-45 days before planned visit

2. IT/Cyber Security Approval with any computer access

3. Regional Manager (or Acting Official) for approval signature

4. Original to Regional Safety and Security Office (The Safety and Security office reviews and sends to

CSO-Security Office)

5. CSO Security (Conducts required inquiries with DOE)

6. Approval sent to Regional Safety and Security Officer

7. Regional Safety and Security Officer notifies host and front desk personnel of approval/denial

To allow time for background checks, this form must be completed at least 30 days for non-sensitive countries visitors, and 45 days for visitors from sensitive countries.

For more information and a list of sensitive countries go to:

http://www.cso.wapa.gov/cpo/3700/SECURITY/fva.htm

(Failure to complete this approval process may result in denial of visit.)

Section A – PERSONAL DATA INFORMATION

BLOCK 1. Employee name: Last name; first name, middle name BLOCK 2. Select Male or Female: Place a check mark in the appropriate box BLOCK 3. Country of Birth: Spell out. No abbreviations BLOCK 4. City of Birth: Spell out. No abbreviations BLOCK 5. Home Address: Self-explanatory BLOCK 6. Date of Birth: Month/Day/Year BLOCK 7. Social Security Number: Self-explanatory BLOCK 8. Country of Citizenship: Spell out. No abbreviations BLOCK 9. Passport/Visa/Immigration Number: One must be supplied BLOCK 10. Country of Issue of Passport/Visa/Immigration Number BLOCK 11. Expiration Date: of above issued document Month/Day/Year

Section B – EMPLOYMENT DATA

BLOCK 12. Current Employer/Business Name: Self-explanatory BLOCK 13. Business Address: Self-explanatory BLOCK 14. Business Phone: Self-explanatory

Section C – COMPUTER ACCESS & NETWORK CONNECTIVITY

BLOCK 15. Do you have computer need: Answer yes or no BLOCK 16. Are you bringing a computer on site: Yes or no BLOCK 17. Do you need access to WAPA’s Information Systems: Yes or no BLOCK 18. Will you need to install software application to perform presentation(s) : Yes or no BLOCK 19. Do you require internet access: Yes or no BLOCK 20. Will the visitor/assignee have external devices (flash drive, removable drive, cd’s, disk, others) : Yes or no

Section D – VISIT DATA INFORMATION

BLOCK 21. Buildings/Sites/Areas to be Visited: Be specific (note: Must be escorted by host at all times) BLOCK 22. Request Date: Date host is submitting this request for approval BLOCK 23. Name and Signature of DOE Host: Must be a supervisor BLOCK 24. Contact # - Host’s # BLOCK 25. Is the host a U.S. Citizen: Yes/No BLOCK 26. Purpose of Visit: State clear purpose/be very specific BLOCK 27. Will sensitive or OUO be discussed? Describe what?

BLOCK 28. Start Date of Visit: Month/Day/Year BLOCK 29. End Date of Visit: Month/Day/Year BLOCK 30. Authorized SES Manager Administrator Signature: Regional Manager or SES.

BLOCK 31. IT/Cyber Security Office Approval: IT/Cyber signature and approval w/any computer access BLOCK 32. Authorized Approval Signature CSO Security Office –visit not approved without this signature

WAPA F 3000-72#

(03/06)

FOREIGN NATIONAL DATA CARD

FOR UNCLASSIFIED FOREIGN VISITS AND ASSIGNMENTS

TO WESTERN AREA POWER ADMINISTRATION

Please print clearly

SECTION A – PERSONAL DATA

1. Name of Visitor: (Last) (First) (Middle)

2. Male Female

3. Country of Birth: 6. Date of Birth: 8. Citizenship:

4. City of Birth: 9. Passport/Visa/Immigration Numbers:

7. Social Security Number:

5. Home Address: 10. Country of Issue:

11. Expiration Date:

SECTION B - EMPLOYMENT DATA

12. Employer/Business Name: 13. Business Address:

14. Phone:

SECTION C – COMPUTER ACCESS AND NETWORK CONNECTIVITY

15. Do you have computer needs? Yes No 16. Are you bringing computer on site? Yes No

17. Do you need access to WAPA’s Information System? Yes No

18. Will you need to install software applications to perform presentation(s)? Yes No

19. Do you require internet access? Yes No 20. Will the visitor/assignee have external devices (flashdrive, removable drive, cd’s, disks, others) that they will be bringing on site? Yes No

SECTION D - VISIT DATA

21. Buildings/Sites to be Visited:

22. Request Date: 23. Name and Signature of DOE Host:

24. Contact #: 25. Is the host a U.S. Citizen?:

Yes No

26. Purpose of Visit/Assignment (be very specific):

27. Will sensitive or Official Use Only (OUO) information be discussed? Yes No If yes, what? (be specific)

28. Start Date of Visit: 29. End Date of Visit:

30. Authorized SES Manager Administrator - Signature: Date:

31. IT/Cyber Security Office Approval - Signature: Date:

32. Security Office Approval - Signature: Date: