Fillable NOTIFICATION OF APPOINTMENT OF FOREIGN GOVERNMENT EMPLOYEE Form DS-2004

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NOTIFICATION OF APPOINTMENT OF FOREIGN GOVERNMENT EMPLOYEE Form DS-2004

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The NOTIFICATION OF APPOINTMENT OF FOREIGN GOVERNMENT EMPLOYEE Form DS-2004 form is 4 pages long and contains:

  • 3 signatures
  • 42 check-boxes
  • 59 other fields

Country of origin: US
File type: PDF

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The US Department of State (DOS) or the State Department, is the government official division that advises the President and performs international relations. Equivalent to the outside service of different nations, it was built up in 1789 as the country's first official department.

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INSTRUCTIONS FOR COMPLETING FORM DS-2004,
NOTIFICATION OF APPOINTMENT
OF FOREIGN GOVERNMENT EMPLOYEE
Please read all instructions before completing this form.
NOTE: It is important that all information provided to the Office of Protocol and the Office of Foreign Missions be consistent. Discrepancies, such as
in the spelling of the name, the residence address, date of birth, etc., may delay processing applications for identification cards, tax exemption cards,
drivers' licenses, and automobile registrations.
The instructions below are numbered to correspond to the numbered items on the form.
PLEASE TYPE ALL ANSWERS.
If employee is a U.S. citizen, the following items do not need to be completed: 8, 9, 10, 16, 17, 18, 20, 21, 22, (unless family member also is employed
by a foreign government or international organization), or 23.
This form is to be completed for all employees of foreign missions except diplomatic and consular officers. All questions should be answered
completely and accurately. If a question does not apply, please type N/A.
Any changes in the information provided on this form should be reported as soon as possible using the Notification of Change, Form DS-2006.
In the case of members of the administrative and technical and service staffs of embassies and consular employees and members of the
service staff of consular posts, the United States does not extend privileges and immunities to persons unless documentation is provided to
indicate that the sending state: (1) pays the cost of the employee's transportation to the U.S. from the employee's normal place of residence; (2)
transfers the employee and his or her immediate family out of the United States within a specific time frame consistent with the sending state's
transfer policy; and (3) pays the cost of the employee's transportation from the United States to the employee's normal place of residence or to
the country of the employee's next assignment.
1
Enter the name of the Embassy or Mission submitting the form.
Give telephone number and email address of office which can be
contacted for further information, if necessary.
2
Enter "X" in the box to indicate if the employee works at an
embassy, consulate, miscellaneous foreign government
office, or mission to an international organization, or is a
personal or domestic employee of a foreign government
official. For personal or domestic employee, check box
corresponding to employer's status (e.g. Embassy, Consular).
3
Enter the officer's full name in the order specified:
(a) surname; (b) given name;
(c) prefix such as Mr., Mrs., Ms., or Miss,
military rank, or title; (d) suffix, such as Jr. or Sr.; and (e) maiden
name. Type "X" to indicate if
male or female.
NOTE: The abbreviated name, if used, will appear in all
publications and documents issued by the U.S. Department of
State.
4
Enter present nationality.
5
Enter employee's date of birth (mm-dd-yyyy).
6
Enter nationality at birth, even if the same as Number 4.
7
Enter employee's place of birth - city and country or state.
8
Enter"X" in box indicating type of passport, if any.*
9
Enter "X" in box indicating type of United States visa held in passport, or
if permanent resident, give alien registration "A" number.
10
Enter date (mm-dd-yyyy), of arrival in the United States and port of entry.
11
Enter residence address (not duty address unless actually living and
working at the same location), in the United States where employee
currently resides. If temporary (hotel, etc.), use Form DS-2006 to notify
the Department of State when officer moves to a permanent address.
DS-2004
11-2017
Instruction page 1 of 2
12
Enter the name, address, and telephone number of foreign mission
consulate, or office where the employee will be assigned. NOTE: For
domestic employees, give the name, Personal
Identification Number (PID), and title of the employer, and his/her
complete office address.
13
Enter the name, address, and telephone number of the actual office or
annex where the employee will be working, if different from Number 12.
NOTE: For domestic employees, give the residence address where
domestic duties will be performed.
NOTE: All addresses must be street addresses, including type,
e.g. Street, Ave., Blvd., etc., not post office box numbers, and must
include ZIP codes and telephone area codes.
14
Enter person's title or position, e.g. secretary, clerk, driver, cook, etc.
Do not use any diplomatic or consular title reserved for officer.
15
Enter the date (mm-dd-yyyy), employee assumed present official
duties in the United States.
16
Enter the date (mm-yyyy) (approximate) that employee will terminate
duties in the United States.*
17
Enter name, title and (PID), if available, of the person the employee is
replacing. Enter date (mm-yyyy), of termination of predecessor. If new
position, so state. (Not applicable for domestic workers.)*
18
If employee will serve in any official capacity other than that that
listed in Number 14, enter position title and mission. Separate
notification will be required.*
20
If not listed in item 21, enter dates (mm-yyyy), nature of all previous
assignments (including study and training) and place (city and state)
in the United States. List To/From month/Year (mm-yyyy)*.
21
Enter the dates (mm-yyyy), nature of employment (job title and
employer), and place (city and country) of academic study or other
activities for previous 5 years, starting from the most recent
assignment prior to this one. List to/From--Month/Year (mm-yyyy).
(NOTE: For Numbers, 20, 21, attach additional sheet, if necessary.)*
19
If a family member (spouse or dependent) is or will be employed in
the United States by a foreign government or international
organization, please identify and indicate position or title,
relationship and where the person is working. The person must be
notified separately to the Office of Protocol using the appropriate
form.
22
Enter names of all eligible family members residing in the household
in the United States, following the same format as in Number 3
above. Use Form DS-2007 for additional names. Give date of birth
(mm-dd-yyyy), place of birth, (city country), current citizenship, and
relationship to principle employee. Enter type of United States visa
(A-1, B-2, etc.) currently held, or copy of Permanent Resident Alien
card.
23
Enter "X" in appropriate boxes for an identification card. For
embassy A&T staff (a) principals (who are not U.S. citizens,
permanent resident aliens or determined to be "permanently resident
in the U.S.), (b) spouses (except U.S. citizens, spouses of persons
determined to be "permanently resident in" the U.S., and permanent
resident aliens), (c) dependents of persons determined to be
"permanent resident aliens and dependents of person determined to
be "permanent resident in" the U.S.)
who are unmarried children between 16 and 21 years who reside
with their parents or are full-time students, or unmarried children
under 23 years who are full-time students (for students between 21
and 23 attach family status justification form), for consular officers
only the consular employees and embassy service staff, principals
(who are not U.S. citizens, permanent resident aliens or determined
to be "permanently resident in" the U.S.) unless the sending state
and the U.S. have entered into a bilateral agreement extending
immunity to family members. Other employees and family members
do not receive identification cards.* The employee must sign and
date (mm-dd-yyyy) the form. In case of domestic employees, the
official employers must also sign and date the form. The form must
be signed and dated (mm-dd-yyyy) by the designated approving
embassy official and the official embassy seal must
be affixed.
*Not required if person being registered is U.S. Citizen or Permanent Resident Alien
Submit forms and attachments to
U.S. Department of State
3507 International Place, NW
Washington, DC 20008-3034
ANY CHANGES IN THE INFORMATION PROVIDED ON THIS FORM SHOULD BE REPORTED AS SOON AS POSSIBLE USING THE NOTIFICATION OF CHANGE,
FORM DS-2006.
DS-2004
Instruction page 2 of 2
(b) Given Name
(e) Maiden(c) Prefix or Rank (d) Suffix
1.From (Name of Embassy/Mission)
10. Last Arrival in U.S.A.
NOTIFICATION OF APPOINTMENT
OF FOREIGN GOVERNMENT EMPLOYEE
TO: Secretary of State, Attention - Department of State
Contact Name, Telephone Number and Email Address
2. Type of Officer
EMB.
CON.
Embassy
Consular
Miscellaneous
Mission to International Organization
Private Domestic
3. Full Name
(a) Surname (Last)
Male Female
4. Current Citizenship
6. Citizenship at Birth 7. Place of Birth
8. Type of Passport
Diplomatic Official Regular Other
9. Type of VISA
A1 A2 Other
G1 G2 G3 G4
(Specify type)
OMB APPROVAL NO. 1405-0105
EXPIRATION DATE: 05-31-2021
ESTIMATED BURDEN: 20 MINUTES *
Date (mm-dd-yyyy)
5. Date of Birth
Port of Entry
11. Residence Address
Temporary Permanent
Number Street (Ave., Blvd., Place, Etc.)
Apt.
City
State ZIP
Telephone
12. Employing Office
Number
Street (Ave., Blvd., Place, Etc.)
Suite
City
State Zip
Telephone
Name of Office
13. Duty Office (If different from employing office)
Number Street (Ave., Blvd., Place, Etc.)
Suite
City
State Zip
Telephone
Name of Office
Ext. Ext.
15. Date of Entry on Duty (mm-dd-yyyy)14. Job Title
16. Expected Date of Departure
17. Name, Title and PID (If Available) of Predecessor and
Date of Termination
18. Will Officer serve in another official capacity?
Yes No
If Yes, give position and duty office:
19. Are there any immediate family member employed by a foreign
government in the United States?
Yes No
If Yes, give names and duty office:
Each person must submit a separate notification of appointment.
FOR OFFICIAL USE ONLY
P R
A T
PID
MISC.
MISSION TO INTL.
(FOR DOMESTIC EMPLOYEES: See instructions for item #12.) (FOR DOMESTIC EMPLOYEES: See instructions for item #13.)
G5
A3
Permanent Resident: A
For A3 & G5, Give I-94 Expiration Date (mm-dd-yyyy)
DS-2004
11-2017
Page 1 of 2
(mm-dd-yyyy)
(City, Country)
(mm-yyyy)
(mm-dd-yyyy)
U.S. Department of State
International
Organization
dd mmm yyyy
21. All assignments/positions/academic studies/other activities within past five years
(Dates, nature of activity, and location - beginning with most recent) (List To/From (mm-yyyy))
Signature of Applicant
20. All previous foreign assignments within the United States. (If not listed in item 21 below, including study and training)
(List To/From (mm-yyyy))
22. Family Members Residing in Household in The United States (Use DS-2007 continuation sheet if necessary; staple to this form.)
(a) Surname (b) Given Name
(c) Prefix (d) Suffix
(e) Maiden (f) Other
Male Female
Citizenship
I understand that, if I am at present engaged in, or proposed to engage in, any activity on behalf of a foreign government as a public relations counsel, publicity
agent, or information service employee, I must register with the Attorney General in accordance with 22 U.S.C. 612.
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 Diplomatic Relations,
1961, Article 41; Vienna Convention on Consular Relations, 1963, Article 55).
Date (mm-dd-yyyy)
Typed Name and Signature of Chief of Mission or Authorized Deputy
Date (mm-dd-yyyy)
(Embassy Seal)
*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.
(g) Relationship
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 foreign government employees 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.
For Employee:
Yes No
For Dependents:
Yes No
Employer's Signature (For Private Domestic Employees)
Date (mm-dd-yyyy)
ANY CHANGES IN THIS INFORMATION MUST BE REPORTED IMMEDIATELY TO THE DEPARTMENT OF STATE (USE FORM DS-2006, NOTIFICATION OF CHANGE)
23. Please indicate if requesting identification cards
DS-2004
PRIVACY ACT and PAPERWORK REDUCTION ACT STATEMENTS
Place of Birth (City, Country)Date of Birth (mm-dd-yyyy) VISA Status
Page 2 of 2
(Not applicable for International organizational personnel)
(Not applicable for International organizational personnel)
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NOTIFICATION OF APPOINTMENT OF FOREIGN GOVERNMENT EMPLOYEE Form DS-2004

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Completed 15 May 2019

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