DS-3037 Update of Information on Exchange Visitor Program Sponso

INSTRUCTIONS
The U.S. Department of State records on Exchange Visitor Program Sponsors must be up-to-date. From time
to time, lists of Program Sponsors, their addresses, names of personnel authorized to sign the DS-2019,
(Responsible Officers and/or Alternate Responsible Officers) are provided to U.S. Consuls and Immigration
Officers so that they may verify the validity of DS-2019 forms presented to them. If records are not up-to-date, it
is possible that a U.S. Consul or Immigration Officer might refuse to accept a DS-2019.
THIS FORM SHOULD BE FILLED OUT AS FOLLOWS:
Enter the Program Number as it appears in the U. S. Department of State records, followed by the name of the
institution/organization as it is currently recorded. (Do not use Roman numbers in the Program Number.)
1-4. Enter any appropriate changes of program address, telephone number, fax number, and/or
Responsible Officer.
5. Enter any changes in Alternate Responsible Officer(s). (Indicate names(s) of previous Alternate
Responsible Officer(s), if replacing).
PLEASE INCLUDE A CITIZENSHIP CERTIFICATION FOR EACH RESPONSIBLE AND ALTERNATE
RESPONSIBLE OFFICER
I hereby certify that I am the responsible(or alternate)officer for this program, and that I am a citizen of the United
States (or a person lawfully admitted to the United States for legal 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 account for all DS-2019 forms transferred to it (22 CFR 62.2).
I also understand that false certification may subject me to criminal prosecution under 18 U.S.C. 1001, which
reads: "Except as other wise 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 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

6. If you wish to receive an allotment of DS-2019 forms, indicate the number of forms. If an increase in
program levels is requested, please provide a letter of explanation for the increase.
7.

Indicate the number of additional copies of this form, Codes for Educational and Cultural Exchange or
the Exchange Visitor Program brochure requested.

8.
If you desire, you may request that the Exchange Visitor Program indicated on this form be
cancelled. (Cancellation of an Exchange Visitor Program by the sponsor will not preclude the
establishment of a new program at a later date.)
PLEASE SEND CORRESPONDENCE TO:
Office of Designation
Bureau of Educational and Cultural Affairs
SA-5, 5th Floor
Department of State
Washington, DC 20522-0505
* Under the Mutual Educational and Cultural Exchange Act of 1961, as amended, the U.S. Department of State 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/GIS/DIR, U.S. Department of State, Washington, DC 20520.
DS-3037
02-2010

Instruction Page 1 of 1

U.S. Department of State

PRIVATE SECTOR EXCHANGES
OFFICE OF DESIGNATION

OMB APPROVAL NO. 1405-XXXX
EXPIRATION DATE:
ESTIMATED BURDEN:

UPDATE OF INFORMATION ON EXCHANGE VISITOR PROGRAM SPONSOR
Exchange Visitor Program Number
Program Sponsor Name

1.

Change the name of the Program Sponsor from the above to
(New Articles of Incorporation designating legal name change must be submitted with request.)

2.

Change the address of the Program Sponsor
FROM:

3.

TO:

( ) Change the telephone number from

to

( ) Change the fax number from

to

( ) Change the email address from

to

CITIZENSHIP IS REQUIRED FOR EACH RESPONSIBLE AND ALTERNATE RESPONSIBLE OFFICER,
SEE PAGE 1
4.

( ) Change the Responsible Officer of the above
. program from:
.

to
5. Add the following Alternate Responsible
Officer(s)
Name (Last,First)

Telephone number and Email Address

Name (Last,First)

Telephone number and Email Address

Name (Last,First)

Telephone number and Email Address

Name (Last,First)

Telephone number and Email Address
(PLEASE ALLOW FOUR TO SIX WEEKS
FOR ALLOTMENT OF FORMS (22 CFR 62.12(a))

6.

( ) DS-2019

(Indicate number).

7a. ( ) Exchange Visitor Program "Welcome" brochure:

(Indicate number.)

7b. ( ) Au Pair Program Brochure

(Indicate number.)

8.

( ) Cancel the above named Exchange Visitor Program

Signature of Responsible or Alternate Responsible Officer

Title of Signing Officer
DS-3037

(designated program sponsor.)

Print Name

Date (mm-dd-yyyy)
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