Egypt_Base_Pass_Questionnaire.pdf

BASE PASS QUESTIONNAIRE

Please fill in the appropriate information below. Complete items marked with an asterisk (*) as applicable.

A. Individual's Information:

*1. Name in full (in English):

*2. Name in full (in Arabic):

*3. Nationality: (i.e., American, British, Egyptian, etc…)

*4. Religion: (i.e., Protestant, Catholic, Muslim, etc…)

*5. Date of Birth:

*6. Place of Birth:

7. Marital Status: (i.e., Single, Married, Divorced, etc..)

*8. Occupation/Specialization: (i.e., Engineer, Project Manager, etc…)

9. Work assigned to do in Cairo: Attend site visit to assist with proposal preparation

*10. Passport # (mention the symbol or letter shown before the #):

*10a. Copy of Passport picture and signature page:

*10b. For local provide copy of national ID:

*11. Date of Issue:

*12. Expiration Date:

*13. Local (Egypt) Address: (local address-hotel for visitors; home address for local Egyptians)

*14. Address in U.S.A.: (or address in the country of origin-home address)

15. Purpose of Visit (Specific details): Attend a site visit in order to prepare a proposal to perform work in support of the Egyptian Military (Air Defense).

*16. Interval of time required: From: To:

17. Establishments to be visited: Almaza and Wadi Houf

18. Organization which recommended the individual’s presence:

19. Number of Solicitation: W912ER-15-T-0019

*20. Company name and phone number: