Form FS-6500-1 Foreign Travel Proposal

USDA - Forest Service

FS-6500-1 (4/2008) OMB 0596-NEW (Expiration XX/2011)

FOREIGN TRAVEL PROPOSAL (Reference FSH 6509.33) THIS FORM MUST BE COMPLETED ELECTRONICALLY, USE CONTINUATION SHEET IF NECESSARY

PART I - IDENTIFYING UNIT & DESTINATION

1. Location :

2. Fiscal Year

3. Deputy Area

4. Legal Name of Traveler : First , Middle, Last

    

Name

     

Work Title

     

Grade

     

5. Staff

6. Destination (city and country)

7. Departure Date

8. Return Date

     

     

     

     

9. Purpose of Travel (NO Acronyms or Abbreviations) Note: Attach Flight Itinerary

Attend Meeting (identify name of meeting)

     

b. Other (be Specific)

     

PART II - ESTIMATED TRAVEL COSTS

1. Transportation

2. Per Diem

3. Miscellaneous

Total

4 . Source: Outside of your FS Unit Funding

$     

$     

$     

$0.00

     

5. Cost to your FS Unit

6. Outside Funding

7. Total Cost (blocks 5 & 6)

8. FS Budget Code

$     

$     

$0.00

     

PART III - REMARKS

Mailing/Contact/Security Clearance Information (Note: All information is mandatory)

Office Address (NO P.O. Box)

Office

     

Phone Number:

     

Street

     

FAX Number:

     

Suite

     

E-mail address:

     

City, State , Zip

     

Cell phone number:

     

Your Security Clearance:

None  Secret  Top Secret (most employees do not have this security level)

Passport

Do you have a valid official passport?

Yes No

Expiration Date      

Do you have a personal passport?

Yes No

Issue Date     

Passport Number?

     

Social Security Number( Mandatory for all FS employees ) Date of Birth:       Place of Birth:       Social Security Number:      

Is admittance to US Embassy Or Consulate required? Yes No

Name, Title, and Phone of contact in each country listed in Part I, item 6 above:      

Hotel Name , Address , Phone number , and ConfIrmation # where staying in each country listed.      

Emergency Contact (Supervisor) :

Name:      

Title :      

Phone:      

Fax:      

PART IV - SIGNATURES

:      

Date:      

:      

Date:      

:      

Date:      

FOREIGN TRAVEL PROPOSAL – CONTINUATION SHEET (Reference FSH 6509.33) THIS FORM MUST BE COMPLETED ELECTRONICALLY
PART I - IDENTIFYING UNIT & DESTINATION
Part I, Item 6. Destination (city and country)      	7. From (Date):	8. To (Date):
	     	     
     	     	     
     	     	     
     	     	     
     	     	     
PART III - REMARKS
Part III, Item 5. Name of contact in each country listed in Part I, item 6      	Title	Phone Number
	     	     
     	     	     
     	     	     
     	     	     
     	     	     
Part III, Item 6. Hotel Name, Address where staying in each country listed in Part I, item 6      	10. Phone Number	11. Confirmation Number
	     	     
     	     	     
     	     	     
     	     	     
     	     	     

PRIVACY ACT STATEMENT

Executive Order 9397 authorizes the collection and use of Social Security Numbers and Public Law 107-71 authorizes the collection and use of Passport Numbers. Collection and use are covered under Privacy Act System of Records USDA/OP-1 (Personnel and Payroll System for USDA Employees) and are consistent with the provisions of 5 USC 552a (Privacy Act of 1974).

PURPOSE: To facilitate the timely issuance of foreign travel requests, including and not limited to: Release of official US government passport, Issuance of official US government passports; Renewal of official US government passports; and visas, if necessary.

CATEGORIES OF INDIVIDUALS COVERED BY THE SYSTEM: Current and prior employees of USDA and applications who were not hired, as well as permittees, cooperators, and contractors

ROUTINE USE(S): This information will be matched with lists at other Federal agencies such as the State Department and USDA Foreign Agricultural Service (Department of State's designated USDA control point for all Official and Diplomatic passports) to ensure that you are listed as a Forest Service employee and for verification to your employment status. Information will be gathered on the Forest Service form FS-6500-1 and then transferred to the USDA form AD-121

DISCLOSURE: Voluntary; however, failure to furnish the information on this form may result in disapproval of your travel request or issuance of your passport.

BURDEN AND NONDISCRIMINATION STATEMENTS

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0596-NEW. The time required to complete this information collection is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any public assistance. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at 202-720-2600 (voice and TDD).

To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call toll free (866) 632-9992 (voice). TDD users can contact USDA through local relay or the Federal relay at (800) 877-8339 (TDD) or (866) 377-8642 (relay voice). USDA is an equal opportunity provider and employer.

INSTRUCTIONS

PART I – IDENTIFYING UNIT & DESTINATION

1. Location: Please select Region/Station or other location from drop down menu.

2. Fiscal Year: Forest Service fiscal year runs from October 1 – September 30, enter fiscal year during which travel will occur.

3. Deputy Area: Please select the area covering employment, for example: National Forest System; Research & Development, etc. from the drop down menu.

4. Legal Name of Traveler: DO NOT USE NICK NAMES, this is your legal given name, enter First; Middle; Last

5. Staff: This is for WO employees only

6. Destination: Enter all countries in which you will be working. If more than one country, please use the CONTINUATION SHEET. Continuation Sheet not needed if only going to one destination.

7. Departure Date: This is the date departing the U.S. Be accurate, visas and country clearance based on this information. DO NOT PAD.

8. Return Date: This is the date departing last country of work.

9. Purpose of Travel: IMPORTANT: NO ACRONYMS. Spell it out, exception: U.S. or FS. Be specific. If attending a meeting, provide the name of the meeting. If traveling for research, outline type of research to be done. DO NOT USE “SITE VISIT.” ATTACH FLIGHT ITINERARY OR SEND AS SOON AS RESERVATIONS CONFIRMED.

PART II – ESTIMATED TRAVEL COSTS

1. Transportation: The cost of your tickets

2. Per Diem: The total cost of your M&IE for all days being claimed

3. Miscellaneous: Amount you needs to cover approved expenses not covered under M&IE. Blocks 1, 2, and 3 will automatically total.

4. Source of Funding: Outside of your FS Unit Funding, is someone else paying for all or part of trip? Insert affiliation, for example: If the WO/International Programs is paying, insert WO/IP; if payment coming from outside the Federal government, enter source such as University grant.

5. Cost to your FS Unit: This is how much your Forest Service office is paying

6. Outside Funding: This is how much block 4 is paying

7. Total cost (blocks 5 & 6): This should total automatically and be the same as the total block above.

8. FS Budget Code: Insert budget code from either your unit or WO/International Programs

PART III – REMARKS

1. Mailing/Contact/Security Clearance - Note: This information is MANDATORY; failure to furnish may result in request not being processed in a timely manor.

MAILING and CONTACT INFORMATION: This should be your work address and will be used to send you your passport. We send everything Federal Express, so no P.O. Box, please. Include your work phone number; Fax; email (where you may be reached); and cell phone number (in case International Travel Office needs to contact you).

Security clearance: Please indicate NONE; SECRET; TOP SECRET. International Travel Office checks FS Security for both issue and expiration dates, if a clearance has been indicated.

2. Passport:

Do you have a valid official passport, yes or no: if yes, provide number and expiration date.

Do you have a personal passport, yes or no: if yes, provide number and issue/expiration date.

3. Social Security Number: Mandatory for FS Employees (if you are NOT an FS employee, DO NOT complete)

4. Do you require admittance to US Embassy or Consulate? Yes or No

This is used on your country clearance cable. Our embassies want to know if you will need to enter the building.

3. Name, Title and Phone of contact IN EACH country listed in Part I, item 6 or on continuation sheet. DO NOT USE someone here in the U.S.

4. Hotel name, Address, Phone number and Confirmation number where you will stay in each country listed in Part I, item 6. List here or on continuation sheet. Please also include dates of stay.

5. Emergency Contact (Supervisor) enter their name, title, phone and fax

PART IV – SIGNATURES

This is a drop down box. No signatures required to send this form to WO/Travel. Signatures are required to send this form to the ASC.

TRANSMISSION: ELECTRONICALLY SUBMIT THIS FORM TO [email protected]