(4) A retired member of the U.S. Department of State Foreign Service?
*Public reporting burden for this collection of information is estimated to average 20 minutes per response, including time required for searching existing
data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final collection. You do not
have to supply this information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy of this burden
estimate and/or recommendations for reducing it, please send them to: M/OFM, 3507 International Place NW, Washington, DC 20008.
Signature of Chief of Mission or Deputy
Signature of Applicant Date
18. Conflict of Interest (To be answered by applicant)
Attach recent color
2" x 2"
Print name and mission on
back of each photo
Intentional provision of false information on this form violates United States law (Title 18 U.S. Code, Section
1001) and will be considered a violation of the international legal obligation of foreign missions and their
personnel to respect the laws of the receiving state (Vienna Convention on Consular Relations, 1963, Article 55).
Any changes in the information provided on this form should be reported as
soon as possible using the Notification of Change, Form DS-2006.
Page 2 of 2
a. (1) Do you hold a position of profit or trust with the Federal Government?
If answer is "Yes", identify the branch and position held.
(Attach description of duties performed.)
(2) Do you hold an office with a state, county, or municipal government in the United States?
If "Yes", attach description of duties performed and include letter from the state, county, or municipality stating
that your position is not incompatible with the duties of a foreign consular officer, and that they have no objection
to your consular appointment.
b. Are you:
If "Yes", state which:
(1) A retired member of the uniformed services of the United States (meaning the Armed Forces, the commissioned Regular and Reserve
corps of the Public Health Service, or the commissioned corps of the National Oceanic and Atmospheric Administration)?
If "Yes", attach copy of letter of permission from the Secretary of the Department concerned.
(3) A member of the Commissioned Reserve Corps of the United States Public Health Service?
(2) A member of a reserve component of the armed forces of the United States (meaning the Army, Navy, Air Force, Marine Corps, or
The Privacy Act of 1974, as amended, 5 U.S.C. 552a, contains provisions regarding the maintenance, collection, use, and dissemination of information
about United States citizens and aliens lawfully admitted for permanent residence in the United States. The following information is provided in
accordance with subsection (e)(3) of the Privacy Act.
AUTHORITIES: The information is sought pursuant to Vienna Convention on Diplomatic Relations of 1961; Vienna Convention on Consular Relations of
1963; Diplomatic Relations Act (22 U.S.C. 254a-e); and International Organizations Immunities Act (22 U.S.C. 288e (a)).
PURPOSE: The principal purpose for the collection of this information is to notify the U.S. Department of State of the appointment of honorary consular
officers so the Department can therefore extend various privileges and benefits granted by the above-cited authorities which are predicated upon review
and acceptance of this information by the U.S. Department of State.
ROUTINE USES: The principal users of this information are offices within the U.S. Department of State, including but not limited to, the Office of Protocol,
the Office of Foreign Missions, and the Office of Visa Services. In response to inquiries from law enforcement agencies, the Office of Protocol may
confirm status as recognized by the U.S. Department of State as covered under STATE 36, Security Records. Information may also be provided to other
government agencies having statutory or other lawful authority to maintain such information. Names of the members of diplomatic staff, office addresses,
titles, and names of spouses are published quarterly in the Diplomatic List, U.S. Department of State Publication 10424. Names of Consular Officers,
titles, and office addresses are published semi-annually in Foreign Consular Offices in the United States, U.S. Department of State Publication 10277.
DISCLOSURE: Providing this information is mandatory. Failure to provide the information requested on this form may prevent acceptance and the
extension of benefits to principals or family members as provided in the above-cited authorities.
PRIVACY ACT and PAPERWORK REDUCTION ACT STATEMENTS
Chief of Mission or Deputy
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