Form OSY Form 207.12 OSY Form 207.12 Form A

DOC Foreign National Request
Form A
Instructions (This form must be typed and completed by Departmental Sponsor).
This form is used for investigative purposes, and, once completed and submitted to your Field Servicing Security Office
(FSSO), constitutes your obligation to meet the notification requirements outlined in DAO 207-12, Section 5.06. This
form must be completed for all Foreign National (non-U.S. National) Visitor and Guest requests.
Note: Questions #2, 3, 4, and 6 may be omitted for Lawful Permanent Residents presenting valid alien registration credentials (e.g., Form I-551,
"Green Card"). For a multi-member visitor group, delegation/or conference, use Appendix (p. 2) to provide or attach required information (#1-7).

Section A.
1. Name: Last

First

Middle

2. Title(s):
3. Date of Birth (MM/DD/YYYY):
4. Gender:

M

5. Contact Email or Phone Number:

F

6. Nationality or Immigration Status:
a. Place of Birth (City/State/Country):
b. Country of Citizenship (List All) or Permanent Residence:
(If lawfully admitted into the U.S. for permanent residence, provide alien registration (i.e., Green Card number))

c. Passport and I-94 Form admission number:
7. Country of Citizenship Sponsoring Organization/Entity:
8. Departmental Sponsor Name and Signature:
(Must be a Federal employee of the Department of Commerce)

9. Sponsor Bureau:

Sponsor Phone Number:

10. Sponsor Email:
11. Facility Number, Name and Address:
City, State and Zip Code:

12. Visit Arrival Date:

Visit Departure Date:

(Per DAO 207-12, the FSSO must be notified about itinerary changes or changes related to the visit)

13. Alternate Point of Contact (name, email, phone):
14. Is this a RENEWAL?

Yes

No

If YES, provide dates of previous visits in Appendix (p. 2).

15. Purpose of Visit: (No acronyms; Be specific (i.e., associated program name, meeting purpose))

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OSY Form 207-12, Form A, October 17, 2018

Name: Last
Visit Arrival Date:

First
Visit Departure Date:

Section B. Appendix. The space below may be used to provide additional visit information or supporting rationale.
Supplemental documentation may be attached, if needed.

Privacy Act Statement:

Authority: The collection of this information is authorized under Department of Commerce (DOC) Departmental Administrative Order (DAO)
207-12, Titled: Foreign Access Management Program; 27 Stat. 395 and 31 Stat. 1039; and all existing, applicable DOC and National Institute of
Standards and Technology (NIST) policies, regulations and directives concerning the tracking, security processing, of Foreign National Visitors and
Guests for access to DOC facilities and support of NIST Associates (NAs) during their tenure at NIST. The foregoing rules are intended to implement,
not to expand upon, the rights granted under the Privacy Act of 1974 (5 U.S.C. § 552a) (Privacy Act).
Purpose: The DOC foreign access management program is designed to enable the broadest cooperation and collaboration with international partners
while ensuring compliance with all applicable United States (U.S.) laws and regulations through consistent and effective management of access by
Foreign Nationals to DOC facilities, resources and activities which are not available to the public. The NA program allows individuals not employed by
NIST to have access to NIST facilities under various cooperative, collaborative, and contractual agreements.
Routine Uses: Information may be shared across DOC Bureaus or Operating Units as necessary, and with the Office of Security, in order to facilitate
access to DOC facilities. Disclosure of this information is also permitted under the Privacy Act to be shared among DOC staff for work-related
purposes. Additionally, this information is subject to all of the routine uses identified in the following Privacy Act System of Records notices: DEPT-13,
Investigative and Security Records, COMMERCE/NIST-1, NIST Associates, and DEPT-25, Access Control and Identity Management System.
Disclosure: Furnishing this information is voluntary; however, failure to provide information will result in the denial of access to DOC facilities by the
subject individual.

Public Reporting Burden Statement:

This collection of information contains Paperwork Reduction Act (PRA) requirements approved by the Office of Management and Budget (OMB).
Notwithstanding any other provisions of the law, no person is required to respond to, nor shall any person be subject to a penalty for failure to comply
with, a collection of information subject to the requirements of the PRA unless that collection of information displays a currently valid OMB control
number. Public reporting burden for this collection is estimated to be 30 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. Send comments
regarding this burden estimate or any aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of
Commerce, Office of the Secretary, Office of Security (OS/OSY), 1401 Constitution Ave., NW, Attn: Harold Washington, Washington, DC 20230.

2

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OSY Form 207-12, Form A, October 17, 2018