REQUEST FOR FOREIGN NATIONAL\
UNCLASSIFIED VISIT OR ASSIGNMENT

Sections A--C are to be completed by the visitor/assignee, and sections
D--H are to be completed by the DOE contact. Once all sections are
completed, the DOE contact faxes the form or sends it via courier
service to the Contractor Security Coordinator. See additional
instructions on page 5. Failure to allow proper processing time may
result in delays.

  ----------------- ------- ------------- --------------- -----------------
  **To be completed                                       
  by the Contractor                                       
  Security                                                
  Coordinator**                                           

  1\. Request                             2\. Visitor          
  Number:                                 Number:         

  3\. Submission              /  /                        
  Date                                                    
  (mm/dd/yyyy):                                           
  ----------------- ------- ------------- --------------- -----------------

  ------------------ -------- ------- ------- ------- ------- ------------ --------- ------- ---------- ------- ------- --------- ------- ------- ------- ----------------
  **Section A --                                                                                                                                          
  VISITOR/ASSIGNEE                                                                                                                                        
  PERSONAL DATA**                                                                                                                                         

  4\. Name:          First:                                                Middle:                                                        Last:           

  Other Names,                                                                                                                                            
  Aliases (Maiden                                                                                                                                         
  Name, etc.):                                                                                                                                            

  5\. Date of Birth                                             /  /                         6\. Gender                 Female                            Male
  (mm/dd/yyyy):                                                                                                                                           

  7\. Place of                City:                                                          Country:                                                     
  Birth:                                                                                                                                                  

  8\. Education                                                                              Field of                                                     
  Level:                                                                                     Study:                                                       
  ------------------ -------- ------- ------- ------- ------- ------------ --------- ------- ---------- ------- ------- --------- ------- ------- ------- ----------------

  ------------------ ------- ------- ------- ------ ------- ------------- ----- ------------ ------------ ---------- ------- --------- --------------- ------- ------- ----- -------- ------------
  **Section B --                                                                                                                                                                      
  VISITOR                                                                                                                                                                             
  CITIZENSHIP**                                                                                                                                                                       

  9\. Citizenship:                                                                                                                                                                    

  Dual Citizenship?                          Yes                          No                              If Yes,                                                                     
                                                                                                          List                                                                        
                                                                                                          Country:                                                                    

  10\. Is                                                                                                                              Yes                             No             
  Visitor/Assignee                                                                                                                                                                    
  Currently in the                                                                                                                                                                    
  United States?                                                                                                                                                                      

  If Yes, is Visitor                                                                                                                   Yes                             No             
  a Permanent                                                                                                                                                                         
  Resident?                                                                                                                                                                           

  11\. Green Card                                                                                                                      Exp. Date                                        /  /    
  Number:                                                                                                                              (mm/dd/yyyy):                                  

  12\. Social                                                  -  -                                                                                                                   
  Security Number:                                                                                                                                                                    

  13\. Visa Number:                                                                                                          Visa                                                     
                                                                                                                             Type:                                                    

  Visa Exp. Date                                                                  /  /                                                                                                
  (mm/dd/yyyy):                                                                                                                                                                       

  14\. Passport                                                                                                              Country                                                  
  Number:                                                                                                                    of Issue:                                                

  Passport Exp.                                                                                /  /                                                                                   
  Date: (mm/dd/yyyy)                                                                                                                                                                  

  15\. Any                                                                                                                                                                            
  Additional                                                                                                                                                                          
  Biographical                                                                                                                                                                        
  Information?                                                                                                                                                                        
  ------------------ ------- ------- ------- ------ ------- ------------- ----- ------------ ------------ ---------- ------- --------- --------------- ------- ------- ----- -------- ------------

  ----------------- ------- ------- ------- ------- ------- -------------- ------------ -------------- ------- ------- ----------- --------- --------- ------- ---------- ------ -------------- -------------- ------- -----------------
  **Section C --                                                                                                                                                                                                       
  VISITOR                                                                                                                                                                                                              
  EMPLOYMENT                                                                                                                                                                                                           
  INFORMATION**                                                                                                                                                                                                        

  16\. Current                                                                                                         Division:                                                                                       
  Employer:                                                                                                                                                                                                            

  Street:                                                                                                              City:                                                                                           

  State/Province:                                                          Zip/Postal                                                                          Country:                                                
                                                                           Code:                                                                                                                                       

  Employer's                                                                               -   -                                   Fax                                              -   -                              
  Telephone Number:                                                                                                                Number:                                                                             

  17\. Is Work                                                                                                                                                            Yes                                          No
  Location                                                                                                                                                                                                             
  Different From                                                                                                                                                                                                       
  Employer's                                                                                                                                                                                                           
  Address Above?                                                                                                                                                                                                       

  If Yes, List                                                                                                                                                                                                         
  Complete Address:                                                                                                                                                                                                    

  Street:                                                                                                              City:                                                                                           

  State/Province:                                                          Zip/Postal                                                                          Country:                                                
                                                                           Code:                                                                                                                                       

  18\. Visitor's                                                                                                                                                                                                       
  E-mail Address:                                                                                                                                                                                                      

  Visitor's                                                    -   -                                                                         Fax                                                   -   -               
  Telephone Number:                                                                                                                          Number:                                                                   

  19\. Type of                                                                                                                                                                                                         
  Business                                                                                                                                                                                                             
  Conducted by                                                                                                                                                                                                         
  Employer:                                                                                                                                                                                                            

  20\. Visitor's                                                                                                                                                                                                       
  Job Title or                                                                                                                                                                                                         
  Position and                                                                                                                                                                                                         
  Duties:                                                                                                                                                                                                              

  21\. List any                                                                                                                                                                                                        
  U.S. Sponsor:                                                                                                                                                                                                        
  ----------------- ------- ------- ------- ------- ------- -------------- ------------ -------------- ------- ------- ----------- --------- --------- ------- ---------- ------ -------------- -------------- ------- -----------------

  ----------------- ------------- --------------- ------- ------------ ------------ --------------- ------- ------- ------- ------ ------- -- ------ ------ ----- --------------------
  **Section D --                                                                                                                                                  
  VISIT                                                                                                                                                           
  LOCATION/DATE**                                                                                                                                                 

  22\. Type of      Visit                                              One Day                                                                                    
  Request?                                                             High-Level                                                                                 
                                                                       Protocol                                                                                   

                    Assignment                                         Extension to                                                                               
                                                                       Assignment                                                                                 

  23\. LM                                                                                                                                                         
  Destination or                                                                                                                                                  
  Off-Site Meeting                                                                                                                                                
  Location:                                                                                                                                                       

  24\. DOE                                                                                                                                                        
  Buildings and                                                                                                                                                   
  Rooms to be                                                                                                                                                     
  Accessed:                                                                                                                                                       

  25\. Area to be                 Non-Security                                      Property                                                                      Limited Area
  Visited:                                                                          Protection                                                                    

                                  Exclusion Area                                    Sensitive                                                                     
                                                                                    Compartmented                                                                 
                                                                                    Information                                                                   
                                                                                    Facility (SCIF)                                                               

  26\. Desired                                              /  /                                                                                                  
  Start Date                                                                                                                                                      
  (mm/dd/yyyy):                                                                                                                                                   

  Desired End Date                                          /  /                                                                                                  
  (mm/dd/yyyy):                                                                                                                                                   

  Is the Assignment                                                                                                                           Yes           No    
  for Intermittent                                                                                                                                                
  Periods of                                                                                                                                                      
  Access?                                                                                                                                                         

  If Yes, List                                                                                                                                                    
  Total Number of                                                                                                                                                 
  Days On Site:                                                                                                                                                   

  and List Dates                                                                                                                                                  
  *(attach sheet if                                                                                                                                               
  necessary):*                                                                                                                                                    

  27\. Is                                         Yes                  No                                                                                         
  Interpreter                                                                                                                                                     
  Needed?                                                                                                                                                         

  28\. Will Family                                                                                                          Yes                      No           
  Members Accompany                                                                                                                                               
  Visitor?                                                                                                                                                        

  *(If Yes, a                                                                                                                                                     
  Separate Form                                                                                                                                                   
  Must be Submitted                                                                                                                                               
  for Each Family                                                                                                                                                 
  Member)*                                                                                                                                                        
  ----------------- ------------- --------------- ------- ------------ ------------ --------------- ------- ------- ------- ------ ------- -- ------ ------ ----- --------------------

  ------------------ --------------------- ----------- ------ ------- ------ ------- ------------- ----- ------------------------ -------------- ------ ------- -------------
  **Section E --                                                                                                                                                
  REASON FOR VISIT**                                                                                                                                            

  29\. Justification                                                                                                                                            
  for Visit,                                                                                                                                                    
  Including Specific                                                                                                                                            
  Activities or                                                                                                                                                 
  Involvement                                                                                                                                                   
  Planned:                                                                                                                                                      

                                                                                                                                                                

  30\. Will                                            Yes                                         No                                                           
  Sensitive Subjects                                                                                                                                            
  be Discussed?                                                                                                                                                 

  If Yes, List                                                                                                                                                  
  Subjects:                                                                                                                                                     

  31\. Purpose of    Cooperative Research                                                                                                                       
  Visit              and Development                                                                                                                            
                     Agreement (CRADA)                                                                                                                          

                     Material Protection,                                                                                                                       
                     Control, and                                                                                                                               
                     Accounting (MPC&A)                                                                                                                         

                     International Atomic                                                                                                                       
                     Energy Agency (IAEA)                                                                                                                       
                     Inspection                                                                                                                                 

                     IAEA Training                                                                       Commercial/Contractor                                  
                                                                                                         Services                                               

                     Conference Attendance                                                                                        Employment                    

                     Equipment                                                                                                    Experiment                    
                     Repair/Installation                                                                                                                        

                     Information Meeting                                                                                          Media Event                   

                     Initiatives for                                                                                              Maintenance                   
                     Proliferation                                                                                                Work                          
                     Prevention (IPP)                                                                                                                           

                     Tour                                                                                                         Research                      

                     Speech or                                                                                                    Training                      
                     Presentation                                                                                                                               

                     Work for Others (WFO)                                                                                                                      

  32\. International                                                                                                                                            
  Agreement Code (if                                                                                                                                            
  Applicable):                                                                                                                                                  

  33\. Headquarters                                                                                                                                             
  Department Element                                                                                                                                            
  Code:                                                                                                                                                         

  34\. Is this a                                                                                                                                                Yes No
  Student and                                                                                                                                                   
  Exchange Visitor                                                                                                                                              
  Program                                                                                                                                                       
  (DS-2019/IAP-66)                                                                                                                                              
  Assignment?                                                                                                                                                   

  35\. Will There be                                                                                                                             Yes No         
  Interactions With                                                                                                                                             
  Individuals With                                                                                                                                              
  Security                                                                                                                                                      
  Clearances?                                                                                                                                                   

  If Yes, List                                                                       List                                                                       
  Name(s):                                                                           Clearance                                                                  
                                                                                     Type/Level:                                                                

  36\. Is this                                                        Yes No                                                                                    
  Visit/Assignment                                                                                                                                              
  for Employment?                                                                                                                                               
  ------------------ --------------------- ----------- ------ ------- ------ ------- ------------- ----- ------------------------ -------------- ------ ------- -------------

  ------------------ ------- -------- ------------ ------- ------- ------- ------- --------- ------------- ------- ------------- ------- ------- ------- --------
  **Section F -- DOE                                                                                                                                     
  CONTACT/HOST**                                                                                                                                         

  37\. DOE Contact's         First:                                                Middle:                                       Last:                   
  Name:                                                                                                                                                  

  38\. Citizenship                                                                                                                                       
  of DOE Contact:                                                                                                                                        

  39\. DOE Contact's                                                                                                                                     
  Office Phone                                                                                                                                           
  Number:                                                                                                                                                

  40\. Does DOE                                                            Yes No                                  If Yes, List                               
  Contact Have a                                                                                                   Type/Level:                           
  Clearance?                                                                                                                                             

  41\. Host                           Host                                                                                                               
  Information:                        Assigned to                                                                                                        
                                      Visit *(Go                                                                                                         
                                      to Question                                                                                                        
                                      42)*                                                                                                               

                                      No Host                                                                                                            
                                      Designated                                                                                                         
                                      *(Go to                                                                                                            
                                      Question                                                                                                           
                                      46)*                                                                                                               

                                      DOE Contact                                                                                                        
                                      Will Serve                                                                                                         
                                      as Host *(Go                                                                                                       
                                      to Question                                                                                                        
                                      46)*                                                                                                               

  42\. Host's Name:                                                                Middle:                                       Last:                   
  First:                                                                                                                                                 

  43\. Citizenship                                                                                                                                       
  of Host:                                                                                                                                               

  44\. Host's Office                                                                                                                                     
  Phone Number:                                                                                                                                          

  45\. Does Host                                           Yes No                            If Yes, List                                                
  Have a Clearance?                                                                          Type/Level:                                                 
  ------------------ ------- -------- ------------ ------- ------- ------- ------- --------- ------------- ------- ------------- ------- ------- ------- --------

+-------------+----------------+---+-----+----------------------------+
| **Section G |                |   |     |                            |
| -- BENEFIT  |                |   |     |                            |
| TO          |                |   |     |                            |
| DOE         |                |   |     |                            |
| /TECHNOLOGY |                |   |     |                            |
| TRANSFER**  |                |   |     |                            |
+-------------+----------------+---+-----+----------------------------+
| 46\. Cost   | **     **      |   |     |                            |
| to DOE:     |                |   |     |                            |
+-------------+----------------+---+-----+----------------------------+
| 47\. Which  |                |   |     |                            |
| DOE         |                |   |     |                            |
| Mission(s)  |                |   |     |                            |
| Will be     |                |   |     |                            |
| Advanced by |                |   |     |                            |
| this        |                |   |     |                            |
| Visit/      |                |   |     |                            |
| Assignment? |                |   |     |                            |
|             |                |   |     |                            |
|             |                |   |     |                            |
+-------------+----------------+---+-----+----------------------------+
| 48\.        |                | * |     |                            |
| Anticipated |                | * |     |                            |
| Benefits to |                |   |     |                            |
| DOE         |                |   |     |                            |
| Programs:   |                |   |     |                            |
|             |                |   |     |                            |
|             |                |   |     |                            |
|             |                | * |     |                            |
|             |                | * |     |                            |
+-------------+----------------+---+-----+----------------------------+
| 49\. Will   |                |   |     | Yes No                     |
| Visit       |                |   |     |                            |
| /Assignment |                |   |     |                            |
| Include     |                |   |     |                            |
| Transfer of |                |   |     |                            |
| Technology? |                |   |     |                            |
+-------------+----------------+---+-----+----------------------------+
| 50\. If     |                |   | **  |                            |
| Yes,        |                |   |     |                            |
| Describe    |                |   |  ** |                            |
| Technology  |                |   |     |                            |
| to be       |                |   |     |                            |
| T           |                |   |     |                            |
| ransferred: |                |   |     |                            |
+-------------+----------------+---+-----+----------------------------+

  ---------------------- --------------------- ------ ------------------------
  **Section H --                                      
  CYBER-SECURITY**                                    

  51\. Will                                    Yes No 
  Visitor/Assignee be                                 
  Granted Computer                                    
  Access?                                             

  52\. If Granted                                     On Site Off Site None
  Computer Access, is                                 
  the Access On Site or                               
  Off Site?                                           

  53\. List any Hardware                                   
  or Software to Which                                
  Access is Required:                                 

  54\. Any Additional                                 
  Remarks?                                            
  ---------------------- --------------------- ------ ------------------------

  ----------- ----------- ------------- -- ------------- -------------------- -- ----------- --
  **To be                                                                                    
  Completed                                                                                  
  by the DOE                                                                                 
  Manager**                                                                                  

                          Visit is                       Visit is Not                        
                          Approved                       Approved                            

              **     **                                                          **     **   

              DOE Manager                  Signature                             Date        
  ----------- ----------- ------------- -- ------------- -------------------- -- ----------- --

*PRIVACY ACT STATEMENT -- Collection of information requested is for the
purpose of determining unclassified access to facilities operated by the
U.S. Department of Energy (DOE) or its contractors in compliance with
DOE Order 142.3,* Unclassified Foreign Visits & Assignments Program.
*Access to information collected may be provided to appropriate federal
agencies for law enforcement\
purposes. Failure to provide requested information may result in denial
of access to DOE facilities or to DOE personnel.*

**INSTRUCTIONS FOR COMPLETING REQUEST FOR FOREIGN NATIONAL\
UNCLASSIFIED VISIT OR ASSIGNMENT**

This form is used to collect information concerning unclassified
visits/assignments to LM facilities by foreign nationals in compliance
with DOE's *Unclassified Foreign Visits & Assignments Program* (DOE O
142.3). For assignments, this form must be received at least 6 weeks in
advance of the assignment. For visits, form should be submitted at least
4 weeks in advance of the visit. Visits by citizens of sensitive
countries must be reviewed at least 30 days before the scheduled visit.

The DOE contact faxes the completed form to the Contractor Security
Coordinator at (970) 248-7744 or sends it via courier service to:
Contractor Security Coordinator, 2597 B ¾ Road, Grand Junction, CO
81503-1789. If you have questions concerning this form, contact the
Contractor Security Coordinator.

**FORM FIELD INSTRUCTIONS**

*To be completed by the Contractor Security Coordinator:*

1 -- Request number is a unique number assigned by the computer system
to identify individual visitors or assignees.

2 -- Visitor number as assigned by the tracking system.

3 -- Date the request was submitted.

*To be completed by the Visitor or Assignee:*

**Section A -- Visitor/Assignee Personal Data**

4-7 -- Enter personal information. If no middle name, enter "NMN."

8 -- Educational background should include the equivalent of any
post-secondary education.

**Section B -- Visitor Citizenship**

9-10 -- Provide citizenship information.

11-14 -- Complete any information concerning the visitor's lawful
permanent residence/green card number, Social Security number, visa, and
passport.

15 -- Add any additional pertinent biographical information.

**Section C -- Visitor Employment Information**

16 -- Employer name and contact information. Include country/city code
for any international telephone numbers.

17 -- Enter business contact information if different from information
provided in question 16.

18 -- Enter visitor's e-mail address, telephone number, and fax number.

19-21 -- Provide information that describes the business operation and
the visitor's role.

*To be completed by the DOE Contact:*

**Section D -- Visit Location/Date**

22-25 -- State the type of visit and location. If the visit is to a DOE
facility, include the building and room numbers where the visit will
take place.

26 -- List the dates of the visit. Note whether the visit will be
intermittent dates during that period, and the total number of days the
visitor will be at the DOE site. List the dates of planned intermittent
visits, attaching a separate sheet if necessary.

27 -- Indicate whether an interpreter will be needed. When feasible, the
host will arrange for an interpreter.

28 -- State whether family members will accompany the visitor to the DOE
site. If Yes, a separate form must be submitted for each family member.

**Section E -- Reason for Visit**

29 -- Provide justification for the visit and describe any planned
action or involvement during the visit.

30-31 -- Describe any sensitive subjects and list the purpose for the
visit.

32 -- Enter the International Agreement Code with the visit. Enter "NA"
if not applicable.

33 -- Enter the organizational code of the Headquarters office
associated with the visit or assignment.

34 -- State whether the visit is for a Student and Exchange Visitor
Program. A DS-2019 (formally IAP-66) Certificate of Eligibility for
Exchange Visitor Status issued by a college or university must be
attached if\
answering Yes.

35 -- Include information for any personnel with clearances who will
have contact with the visitor.

36 -- State whether the visit/assignment is for employment.

**Section F -- DOE Contact/Host**

37-38 -- Provide name and contact information for the DOE Contact.

39-40 -- List citizenship and clearance information for the DOE Contact.

41 -- State whether a host has been identified.

42-43 -- Provide name and contact information for the host.

44-45 -- List citizenship and clearance information for the host.

**Section G -- Benefit to DOE/Technology Transfer**

46 -- Include estimated cost to DOE.

47-48 -- Describe benefits to DOE associated with the visit.

49-50 -- Describe any technology transfer plans associated with the
visit.

**Section H -- Cyber-Security**

51-54 -- Complete this section if visitor is to be granted
cyber-security access. Cyber-security review and concurrence may be
required based on the visit plan and information provided in this
section.

The Contractor Security Coordinator forwards the request to the DOE
Manager for approval.