Fillable UFV&A Long Format IAP-66 *Gender (circle one): Male (National Security Technologies, LLC)

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UFV&A Long Format IAP-66 *Gender (circle one): Male (National Security Technologies, LLC)

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The UFV&A Long Format IAP-66 *Gender (circle one): Male (National Security Technologies, LLC) form is 2 pages long and contains:

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  • 107 other fields

Country of origin: US
File type: PDF

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* First Name: *Middle: *Last:
*Gender (circle one): Male Female Is Visitor currently in the US? Yes No
*Permanent Resident Alien: Yes No
*Country of Citizenship: *Date of Birth (mm/dd/yyyy):
*Country of Birth: *City of Birth:
Affiliation or Company Info:
*Institution or Company Name: Phone Number:
Street (1): Fax Number:
Street (2): E-mail Address:
City: State:
Zip Code: *Country of Employer:
*Title or Position and Duties:
First Name: Middle: Last:
First Name: Middle: Last:
First Name: Middle: Last:
Visa Number: Passport Number:
Visa Type: Country of Issue:
Expr Date (mm/dd/yyyy): Expr Date (mm/dd/yyyy):
Company Name: Phone Number:
Street (1): Fax Number:
Street (2): E-mail Address:
City: State:
Zip Code: Title or Position:
Country of Employer:
Interpreter Needed? (circle one): Yes No
Business Type conducted by Employer:
Educational Background:
Field of Research:
Street (1): City:
Street (2): State:
Zip Code:
When completed, this form contains Personally Identifiable Information.
* Denotes Required Information
UFV&A Long Format IAP-66
Employer Information
A
liase
s
Visitor/Assignee:
* Visa / PRA Information * Passport Information
Place of Work (if different from Employer)
Current Address
PERSONALLY IDENTIFIABLE INFORMATION
PERSONALLY IDENTIFIABLE INFORMATION
✔
*Site to be visited:
*Type of Request (circle one): Visit Assignment Off-site
*Will Sensitive Subjects be discussed? (circle one): Yes No
*Is this a High Level Protocol Visit? (circle one): Yes No
*Select the Security Area Type at the Facility (circle one):
Non-Security Area Property Protection Area Limited Area
MAA Exclusion Area SCIF
Middle: *Last:
*Phone:
*Does the Host have a clearance? (circle one): Yes No
*Desired End date:
*Host's First Name:
*Host's Citizenship:
*Desired Start Date (mm/dd/yyyy):
*Purpose of Visit:
*Subjects (may list more than one):
*HDE Code:
*Justification of visit/assignment including specific activities or involvement:
Is the assignment for intermittent access periods? (circle one): Yes No
Number of Days On-Site: Is this Visit/Assignment for Employment? Yes No
Will there be interactions with Individuals with Security Clearances: Yes No
List Individuals:
First Name: Middle: Last:
First Name: Middle: Last:
First Name: Middle: Last:
*List Buildings and Rooms to be accessed:
Building: Room: Type:
Building: Room: Type:
Building: Room: Type:
*Certification of DOE Mission:
*Anticipated benefits to DOE Programs:
*DOE Contact's First Name: Middle: *Last:
*Contact's Phone: *Cost to DOE:
Will Visit/Assignment include transfer of Technology? (circle one): Yes No Unknown
If there is to be technology transferred, describe:
Export License Required: (circle one) Yes No Unknown
Date Export License Requested (mm/dd/yyyy): License D Number: D
Date Export License Granted (mm/dd/yyyy): License D Number: Z
*Will Visitor/Assignee be granted computer access? (circle one): Yes No
If granted computer access, is the access on-site or off-site?: On-Site Off-Site
List any networks to which access is granted:
* Denotes Required Information
Remarks/Comments (or additional information that did not fit above)
UFV&A Request Information/Long Format IAP-66
Host Information
PERSONALLY IDENTIFIABLE INFORMATION
PERSONALLY IDENTIFIABLE INFORMATION
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UFV&A Long Format IAP-66 *Gender (circle one): Male (National Security Technologies, LLC)

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Completed 11 August 2020

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