DHS_Form_11055-Foreign_National_Visitor_Form.pdf

FOREIGN NATIONAL INFORMATION

VISA ISSUANCE LOCATION:

EXPIRATION DATE (MM/DD/YYYY) (MANDATORY):

PASSPORT NUMBER (MANDATORY):

NAME (LAST, FIRST, MIDDLE): PASSPORT COUNTRY OF ISSUE (MANDATORY):

CITY AND COUNTRY OF RESIDENCE:

COUNTRY(IES) OF CITIZENSHIP:

DUAL CITIZENSHIP:

NOYESLEGAL PERMANENT RESIDENT:

CITY AND COUNTRY OF ORIGIN:

DATE OF BIRTH (MM/DD/YYYY):

GENDER:

ALIASES:

FOREIGN NATIONAL INFORMATION (Passport/Visa)

DHS FORM 11055 (10/14)

VISA TYPE:

JOB TITLE OR POSITION:

CONTACT NUMBER:

EMAIL ADDRESS:

EMPLOYER TELEPHONE NUMBER:

CURRENT EMPLOYER (COUNTRY OR COMPANY ADDRESS

(STREET, CITY, STATE, ZIP CODE, COUNTRY):

GOVERNMENT OWNED BUSINESS:

TYPE OF BUSINESS OR ORGANIZATION:

CURRENT EMPLOYER (COUNTRY OR COMPANY):

VISA EXPIRATION DATE (MM/DD/YYYY):

VISA NUMBER:

INSTRUCTIONS

In order to support visits, assignments, and other foreign national screening needs, requestors shall forward this form to the foreign national(s) being considered for screening. This form shall be filled out for each foreign national requiring screening.

ALIEN REGISTRATION NUMBER:

YES NO

FOREIGN NATIONAL INFORMATION (Employer Information)

NOYES

SPONSOR INFORMATION (For Internal Use Only)

EMAIL ADDRESS:

TELEPHONE NUMBER:

OFFICE OR PROGRAM:

COMPONENT:

DATE OF REQUEST:

JOB TITLE OR POSITION:

NAME (LAST, FIRST, MIDDLE):

DHS FORM 11055 (10/14)

VISIT OR EVENT INFORMATION (For Internal Use Only)

TYPE OF VISIT/EVENT:

HOST EMAIL ADDRESS:

HOST TELEPHONE NUMBER:

HOST ORGANIZATION:

NAME AND TITLE OF VISIT HOST OR AFFECTED FEDERAL EMPLOYEE:

DATE(S) OF VISIT OR EVENT:

YES NO

AFFECTED PROGRAM:

CLASSIFICATION OF ACCESS:

DISCLOSURE OF INFORMATION:

PURPOSE OF REQUEST:

LOCATION OF ACCESS:

BACKGROUND (DESCRIBE THE CIRCUMSTANCES SURROUNDING THE SCREENING REQUEST)

PRIVACY ACT STATEMENT

Authority: The collection of this information is authorized by Executive Order 13587, 6 USC 341, PDD 12, DCID 6/4,and Interagency Security Committee Standard, “Physical Security Criteria for Federal Facilities.”

Purpose: DHS will use this information to determine the risks to DHS personnel, facilities, information, systems, and programs, and to further screen foreign nationals to determine if future access may be granted to a DHS facility or program.

Routine Uses: The information will be used by, and disclosed to, DHS Security personnel, contractor employees, or other agents who require the information to mitigate and manage the risks posed to DHS. DHS may also share the information with other government agencies, as necessary.

Disclosure: The requested information is necessary to determine the risk posed to DHS.

Microsoft Word - Foreign Access Security Review Form DRAFT V3 20130206.doc mhughes ..\Artwork\DHS-Form-11055-Banner.jpg

FOREIGN NATIONAL INFORMATION

VISA ISSUANCE LOCATION:

EXPIRATION DATE (MM/DD/YYYY) (MANDATORY):

PASSPORT NUMBER (MANDATORY):

NAME (LAST, FIRST, MIDDLE):

PASSPORT COUNTRY OF ISSUE (MANDATORY):

CITY AND COUNTRY OF RESIDENCE:

COUNTRY(IES) OF CITIZENSHIP:

DUAL CITIZENSHIP:

NO

YES

LEGAL PERMANENT RESIDENT:

CITY AND COUNTRY OF ORIGIN:

DATE OF BIRTH (MM/DD/YYYY):

GENDER:

ALIASES:

FOREIGN NATIONAL INFORMATION (Passport/Visa)

DHS FORM 11055 (10/14)

VISA TYPE:

JOB TITLE OR POSITION:

CONTACT NUMBER:

EMAIL ADDRESS:

EMPLOYER TELEPHONE NUMBER:

CURRENT EMPLOYER (COUNTRY OR COMPANY ADDRESS

(STREET, CITY, STATE, ZIP CODE, COUNTRY):

GOVERNMENT OWNED BUSINESS:

TYPE OF BUSINESS OR ORGANIZATION:

CURRENT EMPLOYER (COUNTRY OR COMPANY):

VISA EXPIRATION DATE (MM/DD/YYYY):

VISA NUMBER:

INSTRUCTIONS

In order to support visits, assignments, and other foreign national screening needs, requestors shall forward this form to the foreign national(s) being considered for screening. This form shall be filled out for each foreign national requiring screening.

ALIEN REGISTRATION NUMBER:

YES

NO

FOREIGN NATIONAL INFORMATION (Employer Information)

NO

YES

SPONSOR INFORMATION (For Internal Use Only)

EMAIL ADDRESS:

TELEPHONE NUMBER:

OFFICE OR PROGRAM:

COMPONENT:

DATE OF REQUEST:

JOB TITLE OR POSITION:

NAME (LAST, FIRST, MIDDLE):

DHS FORM 11055 (10/14)

VISIT OR EVENT INFORMATION (For Internal Use Only)

TYPE OF VISIT/EVENT:

HOST EMAIL ADDRESS:

HOST TELEPHONE NUMBER:

HOST ORGANIZATION:

NAME AND TITLE OF VISIT HOST OR AFFECTED FEDERAL EMPLOYEE:

DATE(S) OF VISIT OR EVENT:

YES

NO

AFFECTED PROGRAM:

CLASSIFICATION OF ACCESS:

DISCLOSURE OF INFORMATION:

PURPOSE OF REQUEST:

LOCATION OF ACCESS:

BACKGROUND (DESCRIBE THE CIRCUMSTANCES SURROUNDING THE SCREENING REQUEST)

PRIVACY ACT STATEMENT

Authority: The collection of this information is authorized by Executive Order 13587, 6 USC 341, PDD 12, DCID 6/4,and Interagency Security Committee Standard, “Physical Security Criteria for Federal Facilities.”

Purpose: DHS will use this information to determine the risks to DHS personnel, facilities, information, systems, and programs, and to further screen foreign nationals to determine if future access may be granted to a DHS facility or program.

Routine Uses: The information will be used by, and disclosed to, DHS Security personnel, contractor employees, or other agents who require the information to mitigate and manage the risks posed to DHS. DHS may also share the information with other government agencies, as necessary.

Disclosure: The requested information is necessary to determine the risk posed to DHS.