SF 7643-IFN (07-2001) Supersedes (12-2000) issue

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# INFORMATION REQUEST FOR FOREIGN NATIONAL

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<tbody>
<tr class="odd">
<td colspan="18"><strong>Part A. Personal Data</strong></td>
</tr>
<tr class="even">
<td colspan="6"><p>Name (Last, First, Middle)</p>
<p>     </p></td>
<td colspan="9"><p>Address as (Mr., Dr., Professor, etc.)</p>
<p>     </p></td>
<td colspan="3"><p>Date of Birth (date format January 1, 1952)</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="12"><p>Place of Birth (City, State/Region/Province)</p>
<p>     </p></td>
<td colspan="6"><p>Country</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="2"><p>Gender</p>
<p> Male Female</p></td>
<td colspan="16"><p>Country(ies) of Citizenship</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="11"><p>Permanent Residence Address</p>
<p>     </p></td>
<td colspan="7"><p>City</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="9"><p>State/Region/Province</p>
<p>     </p></td>
<td colspan="8"><p>Country</p>
<p>     </p></td>
<td><p>Postal Code</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="18"><h2
id="if-visitor-is-a-permanent-resident-alien-a-copy-of-the-ra-card-must-be-forwarded-to-the-fi-office-snlnm-ms-0891-or-fax-844-5709-snlca-ms-9113-or-fax-294-1330.">If
visitor is a Permanent Resident Alien, a copy of the RA card <u>MUST</u>
be forwarded to the FI Office (SNL/NM, MS 0891 or Fax 844-5709 – SNL/CA,
MS 9113 or Fax 294-1330).</h2></td>
</tr>
<tr class="even">
<td colspan="5"><p>Permanent Resident Alien (RA)? Yes No</p>
<p>If Yes, Resident Alien No.      </p></td>
<td colspan="11"><p>Resident Alien Exp. Date (date format January 1,
2000)</p>
<p>     </p></td>
<td colspan="2"><p>Social Security Number</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td><p>Passport Number(s)</p>
<p>     </p></td>
<td colspan="7"><p>Passport Exp. Date(s) (date format January 1,
2000)</p>
<p>     </p></td>
<td colspan="6"><p>VISA Type</p>
<p>     </p></td>
<td colspan="4"><p>VISA Exp. Date(s) (date format January 1, 2000)</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="18"><strong>Part B. Employment Information</strong></td>
</tr>
<tr class="odd">
<td colspan="18"><p>Name of Current Employer</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="18"><p>Address</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="3"><p>City</p>
<p>     </p></td>
<td colspan="7"><p>State/Region/Province</p>
<p>     </p></td>
<td colspan="7"><p>Country</p>
<p>     </p></td>
<td><p>Postal Code</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="4"><p>Business Telephone</p>
<p>     </p></td>
<td colspan="9"><p>Business Fax</p>
<p>     </p></td>
<td colspan="5"><p>E-mail address</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="7"><p>Title or Position/Duties</p>
<p>     </p></td>
<td colspan="11"><p>Field of Expertise</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="18"><p>Name of Place of Work (if different from Current
Employer)</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="18"><p>Address</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="3"><p>City</p>
<p>     </p></td>
<td colspan="7"><p>State/Region/Province</p>
<p>     </p></td>
<td colspan="7"><p>Country</p>
<p>     </p></td>
<td><p>Postal Code</p>
<p>     </p></td>
</tr>
</tbody>
</table>