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FOREIGN VISITOR INFORMATION NAME OF VISITOR LAST FIRST MIDDLE GENDER CITY AND COUNTRY OF BIRTH COUNTRY IES OF CITIZENSHIP GREEN CARD DATE OF BIRTH MM-DD-YY GREEN CARD EXPIRATION DATE MM-DD-YY LAWFUL PERMANENT RESIDENT NUMBER VISA TYPE VISA NUMBER VISA EXPIRATION DATE MM-DD-YY PASSPORT COUNTRY OF ISSUE PASSPORT NUMBER PASSPORT EXPIRATION DATE MM-DD-YY CURRENT EMPLOYER / DIVISION / OFFICE TYPE OF BUSINESS/ORGANIZATION Yes No SOCIAL SECURITY NUMBER EMPLOYER ADDRESS STREET CITY STATE ZIP CODE COUNTRY EMPLOYER PHONE NUMBER VISITOR JOB TITLE / POSITION VISITOR CONTACT NUMBER VISIT INFORMATION DATE OF REQUEST DHS VISITOR HOST NAME LAST FIRST MIDDLE HOST ORGANIZATION ELEMENT DIVISION OFFICE HOST PHONE NUMBER HOST E-MAIL ADDRESS HOST FAX VISIT START DATE VISIT END DATE NUMBER OF DAYS ON SITE UNCLASSIFIED DESCRIPTION OF VISIT PURPOSE / SUBJECTS TO BE DISCUSSED / INTERNATIONAL AGREEMENTS FULL NAME OF ORGANIZATION AND PROGRAM TO BE VISITED FACILITIES TO BE VISITED INCLUDE BUILDING NAME/NUMBER ADDRESS ROOM NUMBERS AND HIGHEST LEVEL OF CLASSIFICATION FOR WHICH THE FACILITY IS ACCREDITED UNCLASSIFIED SECRET SCI REMARKS COORDINATION / SPECIAL REQUIREMENTS REVIEWS DHS Form 11052-1 07/05 DATE E-MAIL COMMENTS INTERNAL SECURITY REP APPROVAL AUTHORITY OTHER REVIEWER PHONE FAX PRIVACY ACT STATEMENT The Privacy Act 552a requires that federal agencies inform individuals at the time information is solicited from them whether the disclosure is mandatory or voluntary by what authority such information is solicited and what uses will be made of the information. The collection of this information is authorized by EO 9397 6 USC 341 44 USC 3101 and EO 12958. Provision of the information concerning foreign visits is mandatory under the provisions of EO 12958. Failure to provide it may impact planned visits. Use of this information is for internal purposes to facilitate visitor processing.. If the visit may involve sharing or disclosure of classified information the host must contact the DHS Foreign Disclosure Officer prior to the visit for guidance. FOREIGN VISITOR INFORMATION NAME OF VISITOR LAST FIRST MIDDLE GENDER CITY AND COUNTRY OF BIRTH COUNTRY IES OF CITIZENSHIP GREEN CARD DATE OF BIRTH MM-DD-YY GREEN CARD EXPIRATION DATE MM-DD-YY LAWFUL PERMANENT RESIDENT NUMBER VISA TYPE VISA NUMBER VISA EXPIRATION DATE MM-DD-YY PASSPORT COUNTRY OF ISSUE PASSPORT NUMBER PASSPORT EXPIRATION DATE MM-DD-YY CURRENT EMPLOYER / DIVISION / OFFICE TYPE OF BUSINESS/ORGANIZATION Yes No SOCIAL SECURITY NUMBER EMPLOYER ADDRESS STREET CITY STATE ZIP CODE COUNTRY EMPLOYER PHONE NUMBER VISITOR JOB TITLE / POSITION VISITOR CONTACT NUMBER VISIT INFORMATION DATE OF REQUEST DHS VISITOR HOST NAME LAST FIRST MIDDLE HOST ORGANIZATION ELEMENT DIVISION OFFICE HOST PHONE NUMBER HOST E-MAIL ADDRESS HOST FAX VISIT START DATE VISIT END DATE NUMBER OF DAYS ON SITE UNCLASSIFIED DESCRIPTION OF VISIT PURPOSE / SUBJECTS TO BE DISCUSSED / INTERNATIONAL AGREEMENTS FULL NAME OF ORGANIZATION AND PROGRAM TO BE VISITED FACILITIES TO BE VISITED INCLUDE BUILDING NAME/NUMBER ADDRESS ROOM NUMBERS AND HIGHEST LEVEL OF CLASSIFICATION FOR WHICH THE FACILITY IS ACCREDITED UNCLASSIFIED SECRET SCI REMARKS COORDINATION / SPECIAL REQUIREMENTS REVIEWS DHS Form 11052-1 07/05 DATE E-MAIL COMMENTS INTERNAL SECURITY REP APPROVAL AUTHORITY OTHER REVIEWER PHONE FAX PRIVACY ACT STATEMENT The Privacy Act 552a requires that federal agencies inform individuals at the time information is solicited from them whether the disclosure is mandatory or voluntary by what authority such information is solicited and what uses will be made of the information. The collection of this information is authorized by EO 9397 6 USC 341 44 USC 3101 and EO 12958. Provision of the information concerning foreign visits is mandatory under the provisions of EO 12958. This form shall be filled out for each visitor including drivers interpreters etc. and each program to be visited. Visitor hosts shall be notified upon approval or disapproval of the visit. If the visit may involve sharing or disclosure of classified information the host must contact the DHS Foreign Disclosure Officer prior to the visit for guidance. FOREIGN VISITOR INFORMATION NAME OF VISITOR LAST FIRST MIDDLE GENDER CITY AND COUNTRY OF BIRTH COUNTRY IES OF CITIZENSHIP GREEN CARD DATE OF BIRTH MM-DD-YY GREEN CARD EXPIRATION DATE MM-DD-YY LAWFUL PERMANENT RESIDENT NUMBER VISA TYPE VISA NUMBER VISA EXPIRATION DATE MM-DD-YY PASSPORT COUNTRY OF ISSUE PASSPORT NUMBER PASSPORT EXPIRATION DATE MM-DD-YY CURRENT EMPLOYER / DIVISION / OFFICE TYPE OF BUSINESS/ORGANIZATION Yes No SOCIAL SECURITY NUMBER EMPLOYER ADDRESS STREET CITY STATE ZIP CODE COUNTRY EMPLOYER PHONE NUMBER VISITOR JOB TITLE / POSITION VISITOR CONTACT NUMBER VISIT INFORMATION DATE OF REQUEST DHS VISITOR HOST NAME LAST FIRST MIDDLE HOST ORGANIZATION ELEMENT DIVISION OFFICE HOST PHONE NUMBER HOST E-MAIL ADDRESS HOST FAX VISIT START DATE VISIT END DATE NUMBER OF DAYS ON SITE UNCLASSIFIED DESCRIPTION OF VISIT PURPOSE / SUBJECTS TO BE DISCUSSED / INTERNATIONAL AGREEMENTS FULL NAME OF ORGANIZATION AND PROGRAM TO BE VISITED FACILITIES TO BE VISITED INCLUDE BUILDING NAME/NUMBER ADDRESS ROOM NUMBERS AND HIGHEST LEVEL OF CLASSIFICATION FOR WHICH THE FACILITY IS ACCREDITED UNCLASSIFIED SECRET SCI REMARKS COORDINATION / SPECIAL REQUIREMENTS REVIEWS DHS Form 11052-1 07/05 DATE E-MAIL COMMENTS INTERNAL SECURITY REP APPROVAL AUTHORITY OTHER REVIEWER PHONE FAX PRIVACY ACT STATEMENT The Privacy Act 552a requires that federal agencies inform individuals at the time information is solicited from them whether the disclosure is mandatory or voluntary by what authority such information is solicited and what uses will be made of the information. The collection of this information is authorized by EO 9397 6 USC 341 44 USC 3101 and EO 12958.