Form DS-4139 Photograph and Signature Card

*OMB APPROVAL NO.1405-xxxx
EXPIRATION DATE:
ESTIMATED BURDEN:

U.S. Department of State

PHOTOGRAPH AND SIGNATURE CARD

1.Card Type Issued

Section 1 Applicant Information

1. Principal's PID

2. Applicant's PID

5. Surname

8. Nationality

For U.S. Government Use Only
(Shaded Area)

3. Mission Type

4.Country

6. Given Name

9. Sex

2. Card Expiration Date (mm-dd-yyyy)

7. Date of Birth (mm-dd-yyyy)

10. Expected Date of Departure (mm-dd-yyyy)

A. Staple color photo here
(Do not staple face)

Section 2 Certifying Authority
WARNING
This information is provided to the U.S. Department of State in accordance with the requirements of United
States law (Title 18, U.S. Code, Section 1001) that all such statements are truthful. False information will be
considered a violation of U.S. law and, therefore, an abuse of the privileges and immunities to which an
individual's status may entitle him or her.
B. Applicant signs below
Certifier's Signature

Date (mm-dd-yyyy)

Name

Title
USE BLACK INK ONLY

DS-4139
02-2010

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Privacy Act Statement for the Foreign Diplomatic Services Application Database and Paperwork Reduction Act Statement
*The Privacy Act of 1974, as amended, 5 U.S.C. 552a contains provisions
regarding the maintenance, collection, use, and dissemination of information
about United States citizens and aliens lawfully admitted for permanent
residence in the United States. The following information is provided in
accordance with subsection (e) (3) of the Privacy Act.

ROUTINES USES: The principal users of this information are offices within the
U.S. Department of State, including but not limited to the Office of Protocol, the
Office of Foreign Missions, and the Office of Visas Services. In responses to
inquiries from law enforcement agencies, the Office of Protocol may confirm
status as recognized by the U.S. Department State. Information may also be
provided to other government agencies having statutory or other lawful
AUTHORITIES: Vienna Convention on Diplomatic Relations of 1961; Vienna
authority to maintain such information. The information provided on this form
Convention on Consular Relations of 1963; Diplomatic Relations Act (22 U.S.C. may be provided to other federal, state, and local government agencies for law
254a-e); International Organizations Immunities Act (22 U.S.C. 288e (a));
enforcement, administrative or other statutorily authorized purposes. This
Foreign Missions Act of 1982 (22 U.S.C. 4301-4316) as amended.
information also may be provided to the employing Foreign government or
international organization. Submission of information into this database is
PURPOSE: The principal purpose of this information is to maintain a record of voluntary; however, failure to provide any of the requested information may
all individuals actively working at foreign missions or international organizations prevent acceptance as a diplomatic or consular officer or other employee of a
in the United States or its territories and who are entitled to a range of
foreign government or international organization, and the extension of benefits
diplomatic or consular benefits, privileges and immunities. This information is
to principals or family members as provided in the above-cited authorities.
maintained by the Office of Foreign Missions at the U.S. Department of State.
The information is collected in order to (a) determine the acceptability of a
For more information, please see the Systems of Record Notice and Privacy
foreign person by the U.S.Department as a diplomatic or consular officer or
Impact Assessment for the Foreign Diplomatic Services Application at
other international organization or foreign government employee; (b) issue
http://www.state.gov/m/a/ips/c22737.htm.
appropriate individuals an official identification card; (c) register mission and
PAPERWORK REDUCTION ACT: Public reporting burden for this collection
personal vehicles and issue appropriate vehicle registrations and license
of information is estimated to average xx minutes per response, including
plates; (d) exempt certain individuals from sales taxes, gasoline taxes, utility
time required for searching existing data sources, gathering the necessary
taxes, and drivers' license registration fees; and (f) determine the eligibility of
imported goods for exemption from duties otherwise imposed by the Bureau of documentation, providing the information and/or documents required, and
reviewing the final collection. You do not have to supply this information
Customs and Border Protection (CPB). It is also used to notify the State
unless this collection displays a currently valid OMB control number. If you
Department of the termination of diplomatic, consular and foreign employees.
have comments on the accuracy of this burden estimate and/or
recommendations for reducing it, please send them to: A/GIS/DIR, Room
Information on such individuals is submitted electronically directly into the
2400 SA-22, U.S. Department of State, Washington, DC 20522-2202.
Foreign Diplomatic Services Application Database by accredited members of
the administrative staff at Foreign missions or international organizations in the
United States, who have been given permission by the Office of Foreign
Missions to enter data into the database. Certain biographical and professional
information is collected from administrative staff in order for the State
Department to determine their eligibility to access and enter information into the
database.

DS-4139

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