Form DS-3036 Exchange Visitor Program Application

INSTRUCTIONS FOR NEW APPLICATION
If additional space is needed for answering any questions, use continuation sheets or plain white paper.
1-3.
Names, address and telephone/fax numbers of organization.
4.
Select type of application.
5.
Select appropriate categories prior to filling out this data. (See 22 CFR 62.2CFR 62 .4 and 22
CFR 62.20-30.)
6-10.
Complete information on program and program sponsor.
IF TRAINING PROGRAM, identify appropriate fields: Agriculture, Forestry and Fishing; Arts & Culture; Aviation;
Construction and Building Trades; Education, and Social Sciences, Library Science, Counseling and Social Services;
Health Related Occupations; Hospitality and Tourism; Information Media and Communications; Management, Business,
Commerce and Finance; Public Administration and Law; and The Sciences, Engineering, Architecture, Mathematics
and, Industrial Occupations.
11-12.

Certification. Citizenship for new applicants requires certification below.

CITIZENSHIP (22 CFR 62.2 and 5)
(a) Organization
I hereby certify that I am an officer of this program with the title of

(specify);

that I am authorized to sign this certification and bind
(name of organization); and that a true copy certified by the

(specify) of such

authorization is attached. I further certify that
(name of organization) is a citizen of the United States as that term is defined at 22 CFR 62.2
(Name of organization) agrees that its inability
to substantiate its representation of citizenship made in this certification will result in the immediate withdrawal of its
designation and the immediate return of or accounting for all DS-2019 forms transferred to it.
(b) Responsible Officer or Alternate Responsible Officer
Alternate Responsible Officer for this program and
Responsible
I hereby certify that I am (Check One)
that I am a citizen of the United States (or a person lawfully admitted to the Unites States for permanent residence).
Name of organization:
agrees that my inability
to substantiate my citizenship or status as a legal permanent resident will result in the immediate withdrawal of
its designation and the immediate return of or accounting for all DS-2019 forms transferred to it (22 CFR 62.2).
I understand that false certification may subject me to criminal prosecution under 18 U.S.C. 1001, which reads:
"Except as otherwise provided in this section, whoever, in any matter within the jurisdiction of the executive,
legislative, or judicial branch of the Government of the United States, knowingly and willfully falsifies, conceals, or
covers up by any trick, scheme, or device a material fact; makes any materially false, fictitious, or fraudulent statement
or representation; or makes or uses any false writing or document knowing the same to contain any materially false,
fictitious, or fraudulent statement or entry; shall be fined under this title or imprisoned not more than 5 years, or both".
Signed in ink (Name):

(Print Name)

Title:
Subscribed and sworn to before me this
DOS USE ONLY
Type of Program:
Subtype if applicable:
No. Forms DS-2019:
Categories:
DS-3036

day of

.

NOTARY PUBLIC

PLEASE RETURN FORM TO:
Office of Exchange Coordination and Designation
Bureau of Educational and Cultural Affairs
U.S. Department of State, SA-44
Washington, DC 20547

Page 1 of 3

U.S. Department of State

EXCHANGE VISITOR PROGRAM APPLICATION
OFFICE OF EXCHANGE COORDINATION AND DESIGNATION
1. Name and Address of Sponsoring Organization

OMB APPROVAL NO. 1405-0147
EXPIRATION DATE: xx/xx/xxxx
ESTIMATED BURDEN: 1 Hour
*See Page 3

Serial No. (DOS Use)

2. Name and Title of Responsible Officer

Telephone/Fax Number

3. Name and Title of Alternate Responsible Officer

Telephone/Fax Number

4. Type of Application
NEW
AMENDMENT
(See top of Page 3)
REDESIGNATION
(See Page 3)

(check one)

SECTION I - PROGRAM PARTICIPANT DATA
5. Participation by Category (indicate the total and approximate duration of participation in each category)
Type

No.

Dur.

Type

No.

Dur.

Type

No.

Dur.

Type

Alien Physician

Au Pair

Camp Counselor

Gov't Vistor

Intern

Int'l Visitor

Professor

Research Scholar

Short-term Scholar

Specialist

Student: Col/Univ

Student: Secondary

Summer Work/Trvl
Teacher
(See Title 22 Code of Federal Regulations, Part 62)

No.

Dur.

Trainee

6. Method of Selection and Arrangements for Financial Support of Exchange Visitor while in the U. S. (specify source and amount of funding, as
appropriate.)

SECTION II - PROGRAM DATA
7. Purpose or Objective

8. Outline of Proposed Activities

9. Arrangements for Supervision

10. Role of Other Organizations Associated with Program (if any)

SECTION III - CERTIFICATION
11. Citizenship Certification of Organization and Responsible Officer
12. I certify that the information given in this application is true to the best of my knowledge and belief and that I have completed appropriate
information on page 3 of this form, if applicable.
Print Name of Responsible Officer
Signature of Responsible Officer

Date (mm/dd/yyyy)

Print Name of Chief Executive Officer
Signature of Chief Executive Officer

Date (mm/dd/yyyy)

(CEO's signature also certifies that the Responsible Officer will be provided sufficient staff and resources to fulfill his/her duties and obligations on
behalf of the sponsor.)
DS-3036

Page 2 of 3

U.S. Department of State

APPLICATION FOR REDESIGNATION AND/OR AMENDMENT
If this application includes an amendment, complete pages 2 and 3. If this application is for redesignation only, complete page 3.
Name of Organization

Program Number:

If your organization is applying for redesignation, please certify to the following:
I hereby certify that as an officer of the organization making application for an exchange program under 22 CFR 62.7 that the following documents
previously submitted to the US Department of State, Office of Exchange Coordination and Designation , and information contained therein has not
changed in any material way since designation/redesignation.
(1)
(2)
(3)
(4)
(5)
(6)
(7)

Evidence of status as a legal entity, such as enabling legislation for public post-secondary educational institutions or Articles of Incorporation and
By-Laws and current Certificate of Good Standing.
Evidence of sponsor's financial solvency.
Evidence of Accreditation if a post-secondary educational institution or a flight training program.
Evidence of Licensing.
Evidence of organization's tax-exempt status, if applicable.
Program categories and activities in which the organization has been engaged have not changed since the previous designation, unless
authorized by DOS.
Citizenship.

Organization

I hereby certify that I am an officer of the above named organization with the title of
;
that I am authorized by the
; to sign this certification and bind the organization and that a true copy of
such authorization is on file with the Office of Exchange Coordination and Designation or is attached. I further certify that the organization holds the
requisite citizenship status vis-a-vis the United States as that term is defined in 22 CFR 62.2 The organization agrees that its inability to substantiate
its representation of citizenship made in this certification will result in the immediate withdrawal of its designation and the immediate return of or
accounting for all DS-2019 forms disbursed to it. Further, I certify that the Responsible/Alternate Responsible Officer(s) of this program will be
provided with sufficient staff and resources to carry out all duties and obligations mandated by program designation and U.S. immigration and
nationality laws pertaining thereto.

Signed in ink (Name)

(Print Name)

Title
CERTIFICATION OF REQUIREMENTS 1-7
I hereby certify that I am the responsible officer for this program, and that I am a citizen of the United States (or a person lawfully admitted to the
United States for permanent residence). The organization agrees that my inability to substantiate my citizenship or status as a permanent resident will
result in the immediate withdrawal of its designation and the immediate return of or accounting for all DS-2019 forms (22 CFR 62.2).
I understand that false certification may subject me to criminal prosecution under 18 U.S.C. 1001, which reads: "Except as otherwise provided in this
section, whoever, in any matter within the jurisdiction of the executive, legislative, or judicial branch of the Government of the United States,
knowingly and willfully falsifies, conceals, or covers up by any trick, scheme, or device a material fact; makes any materially false, fictitious, or
fraudulent statement or representation; or makes or uses any false writing or document knowing the same to contain any materially false, fictitious, or
fraudulent statement or entry, shall be fined under this title or imprisoned not more than 5 years, or both".

Signed in ink (Name)

(Print Name)

Responsible Officer

Title
Signed in ink (Name)

Subscribed and sworn to before me this
DOS USE ONLY
Type of Program:
Subtype, if applicable:
Categories:

(Print Name)

Notary Public

day of

,

.

NOTARY PUBLIC

PLEASE RETURN FORM TO
Office of Exchange Coordination and Designation
Bureau of Educational and Cultural Affairs
US Department of State, SA-44
Washington, DC 20547

OMB NOTICE: Under the Mutual Educational and Cultural Exchange Act of 1961, as amended, the U.S. DOS has been delegated the authority to
designate Exchange Visitor Programs for .U.S. Government agencies, public and private organizations. The information is to be used in evaluating
prospective Exchange Visitor Program sponsors. Responses are mandatory. An Agency/or organization may not conduct or sponsor, and the
respondent is not required to respond to, a collection of information unless it displays a valid OMB control number. Public reporting burden for this
collection of information is estimated to average one (1) hour per response, including the time for reviewing instructions, researching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this
burden estimate or any other aspect of the collection of information, including suggestions for reducing the burden to: A/ISS/DIR, U.S. Department of
State, Washington, DC 20520
DS-3036

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