Ds-4140

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

U.S. Department of State

APPLICATION FOR OFM WEBSITE ACCOUNT
Fax completed application to OFM System Director fax 202-895-3669
Type of Request
New Account

Section 1 Applicant Information

Change to Existing Account

Delete Account

Country

1. Surname

2. Given Name

3. Middle Initial

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

6. Telephone Number

7. E-mail Address

8. Mission of Assignment

9. City

10. State

4. PID

11. ZIP Code

Section 2 User Acknowledgement
I understand that I am authorized to use this account only for the submission of applications for U.S. Department of State, Office of Foreign
Missions and Office of Protocol services for the missions listed in Section 3 of this application. Any other uses of this account are strictly
prohibited. I will not divulge my login or password to any other entity. I will notify OFM Systems if I have any reason to believe my password
has been compromised. I further acknowledge that improper use of this account could result in adverse administrative action against me.
Name

Signature

Telephone

Date (mm-dd-yyyy)

Section 3 Authorized Missions
Mission

State

City

ZIP Code

Section 4 Mission Administrative Officer Acknowledgement
The applicant listed on this form is an accredited member of the Mission of Assignment referenced in Block 8 of Section 1 above. I certify that
applicant should have the rights to submit applications for U.S. Department of State, Office of Foreign Missions and Office of Protocol services
for the Missions listed in Section 3 of this application. I acknowledge if I am made aware of any improper use of this account I will provide all
necessary assistance to address the situation through OFM Systems.
Name

Signature

Telephone

Date (mm-dd-yyyy)
***Mission Seal Required***

Section 5 Office Of Foreign Missions Approval
Name
DS-4140
02-2010

Signature

Date (mm-dd-yyyy)
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Privacy Act and Paperwork Reduction Statement

*AUTHORITIES: Vienna Convention on Diplomatic Relations of 1961; Vienna Convention on Consular Relations of
1963; Diplomatic Relations Act (22 U.S.C. 254a-e); International Organizations Immunities Act (22 U.S.C. 288e (a));
Foreign Missions Act of 1982 (22 U.S.C. 4301-4316) as amended.
PURPOSE: The purpose of this form is to authorize access to the Office of Foreign Missions' electronic data
submission (e-Gov) system. The information solicited on this form will be used to determine eligibility and create user
accounts for the e-Gov system.
ROUTINE USES: The information provided on this form may be provided to other federal, state, and local
government agencies for law enforcement, administrative or other statutorily authorized purposes. This information
also may be provided to the employing foreign government or international organization.
PAPERWORK REDUCTION ACT: *Public reporting burden for this collection of information is estimated to average
xx minutes per response, including time required for searching existing data sources, gathering the necessary
documentation, providing the information and/or documents required, and reviewing the final collection. You do not
have to supply this information unless this collection displays a currently valid OMB control number. If you have
comments on the accuracy of this burden estimate and/or recommendations for reducing it, please send them to:
A/GIS/DIR, Room 2400 SA-22, U.S. Department of State, Washington, DC 20522-2202.

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