INFORMATION REQUEST FOR FOREIGN NATIONAL

> This is a worksheet to collect the information needed to complete the
> online forms.
>
> This form is not connected to the actual database or application.
>
> Note: The completion of this form may reveal sensitive **personal**
> information that may be subject to public access.
>
> **The fields marked with an asterisk\* are required (if applicable).**

<table style="width:100%;">
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<col style="width: 19%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 5%" />
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<col style="width: 2%" />
<col style="width: 9%" />
<col style="width: 5%" />
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<col style="width: 0%" />
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</colgroup>
<tbody>
<tr class="odd">
<td colspan="14">Part A. Personal Data</td>
</tr>
<tr class="even">
<td colspan="10"><p>*Name (Last, First, Middle)</p>
<p>     </p></td>
<td colspan="3"><p>Address as (Mr., Mrs., Ms.)</p>
<p>     </p></td>
<td><p>Nickname</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="3"><p>*Date of Birth (e.g. January 1, 1952)</p>
<p>     </p></td>
<td colspan="7"><p>*Place of Birth (City)</p>
<p>     </p></td>
<td colspan="3"><p>Place of Birth</p>
<p>(State/Region/Province)</p>
<p>     </p></td>
<td><p>*Country of Birth</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="3"><p>Org (Sandia Assigned)</p>
<p>     </p></td>
<td colspan="7"><p>U.S. Social Security Number</p>
<p>     </p></td>
<td colspan="4"><p>Military ID</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="3"><p>*Gender</p>
<p>Male Female</p></td>
<td colspan="11"><p>*Country(ies) of Citizenship</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="14"><p>Permanent Residence Address</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="5">City<br />
     </td>
<td colspan="7"><p>State/Region/Province</p>
<p>     </p></td>
<td><p>Country</p>
<p>     </p></td>
<td><p>Postal Code</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="5"><p>*Lawful Permanent Resident (LPR)?</p>
<p>Yes No</p></td>
<td colspan="7"><p>*If Yes, Resident Alien Number</p>
<p>     </p></td>
<td colspan="2"><p>*Resident Alien Expire Date</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="5"><p>Applied For Naturalization?</p>
<p>Yes No</p></td>
<td colspan="9"><p>If Yes, Date of Application</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="14"><strong>*Passport Information</strong></td>
</tr>
<tr class="odd">
<td colspan="5">*Passport Number(s)</td>
<td colspan="4">*Expiration Date(s)</td>
<td colspan="5">*Passport Country(ies)</td>
</tr>
<tr class="even">
<td colspan="5">     </td>
<td colspan="4">     </td>
<td colspan="5">     </td>
</tr>
<tr class="odd">
<td colspan="5">     </td>
<td colspan="4">     </td>
<td colspan="5">     </td>
</tr>
<tr class="even">
<td colspan="14"><strong>*Visa Information</strong></td>
</tr>
<tr class="odd">
<td><p>*Visa Type</p>
<p>(A-1, A-2, B-1, B-2, E-1, E-2, etc.)</p></td>
<td colspan="3">*Expiration Date(s)</td>
<td colspan="7">*Control Number(s)</td>
<td colspan="3">Comments</td>
</tr>
<tr class="even">
<td>     </td>
<td colspan="3">     </td>
<td colspan="7">     </td>
<td colspan="3">     </td>
</tr>
<tr class="odd">
<td colspan="14"><strong>*Lawful Status Supporting
Documentation</strong></td>
</tr>
<tr class="even">
<td colspan="2"><p>*Documentation Type(s)</p>
<p>( I-94, I-94W, I-20, DS-2019, I-797, EAD, etc.)</p></td>
<td colspan="4">*Issue Date(s)</td>
<td colspan="2">*Expiration Date(s)</td>
<td colspan="6">*Control Number(s)</td>
</tr>
<tr class="odd">
<td colspan="2">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
<td colspan="6">     </td>
</tr>
<tr class="even">
<td colspan="2">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
<td colspan="6">     </td>
</tr>
<tr class="odd">
<td colspan="2">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
<td colspan="6">     </td>
</tr>
<tr class="even">
<td colspan="14"><p>Comments</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="7"><strong>Official Use Only<br />
When completed, this document contains “Official Use Only” information.
May be exempt from public release under the Freedom of Information Act
(5, U.S.C. 552),exemption number and category: 2 Circumvention of
Statute and 6, Personal/Privacy.. Department of Energy review required
before public release. Name/Org: Sandy Smith 4233-3 Date: 4-15-2005.
Guidance (if applicable):</strong></td>
<td colspan="7"></td>
</tr>
</tbody>
</table>

+---------------------------+-------------------+----------+----------+
| **Part B. Employment      |                   |          |          |
| Information**             |                   |          |          |
+---------------------------+-------------------+----------+----------+
| \*Name of Current         |                   |          |          |
| Employer (Provide full    |                   |          |          |
| company name -- not just  |                   |          |          |
| department or division.   |                   |          |          |
| Do not use acronyms.)     |                   |          |          |
|                           |                   |          |          |
|                           |                   |          |          |
+---------------------------+-------------------+----------+----------+
| \*Address                 |                   |          |          |
|                           |                   |          |          |
|                           |                   |          |          |
+---------------------------+-------------------+----------+----------+
| \*City                    | Stat              | \        | \*Postal |
|                           | e/Region/Province | *Country | Code     |
|                           |                   |          |          |
|                           |                   |          |          |
+---------------------------+-------------------+----------+----------+
| \*Business Telephone      | Business Fax      | E-mail   |          |
|                           |                   | address  |          |
|                           |                   |          |          |
|                           |                   |          |          |
+---------------------------+-------------------+----------+----------+
| \*Title or                |                   |          |          |
| Position/Duties           |                   |          |          |
|                           |                   |          |          |
|                           |                   |          |          |
+---------------------------+-------------------+----------+----------+
| Field of Expertise        |                   |          |          |
|                           |                   |          |          |
|                           |                   |          |          |
+---------------------------+-------------------+----------+----------+
| Name of Place of Work (if |                   |          |          |
| different from Current    |                   |          |          |
| Employer)                 |                   |          |          |
|                           |                   |          |          |
|                           |                   |          |          |
+---------------------------+-------------------+----------+----------+
| Address                   |                   |          |          |
|                           |                   |          |          |
|                           |                   |          |          |
+---------------------------+-------------------+----------+----------+
| City                      | Stat              | Country  | Postal   |
|                           | e/Region/Province |          | Code     |
|                           |                   |          |          |
|                           |                   |          |          |
+---------------------------+-------------------+----------+----------+

+---------------------------+------+------------+----------------------+
| **Part C. Education       |      |            |                      |
| Information**             |      |            |                      |
+---------------------------+------+------------+----------------------+
| Name of School Attended   |      |            |                      |
|                           |      |            |                      |
|                           |      |            |                      |
+---------------------------+------+------------+----------------------+
| Address                   |      |            |                      |
|                           |      |            |                      |
|                           |      |            |                      |
+---------------------------+------+------------+----------------------+
| City                      | S    |            | Country              |
|                           | tate |            |                      |
|                           | /Reg |            |                      |
|                           | ion/ |            |                      |
|                           | Prov |            |                      |
|                           | ince |            |                      |
|                           |      |            |                      |
|                           |      |            |                      |
|                           |      |            |                      |
+---------------------------+------+------------+----------------------+
| School Subject            |      |            |                      |
|                           |      |            |                      |
|                           |      |            |                      |
+---------------------------+------+------------+----------------------+
| School Degree             |      | School     |                      |
|                           |      | Degree     |                      |
|                           |      | Year       |                      |
|                           |      |            |                      |
|                           |      |            |                      |
+---------------------------+------+------------+----------------------+
| School Honors             |      |            |                      |
|                           |      |            |                      |
|                           |      |            |                      |
+---------------------------+------+------------+----------------------+