Form BPA F 5632_08 BPA F 5632_08 Unclassified Visits and Assignments - Foreign Nationals

BPA F 5632.08e

OMB

U.S. DEPARTMENT OF ENERGY
BONNEVILLE POWER ADMINISTRATION

(08-18)
Page 1of 3

UNCLASSIFIED VISITS AND ASSIGNMENTS - FOREIGN
NATIONALS REGISTRATION (SHORT FORM)

Privacy Notice: The information on this form is requested to determine access to facilities operated by the Bonneville Power
Administration (BPA) or its contractors. Access to the information collected will be provided to the Department of Energy, and may be
provided to appropriate Federal agencies for law enforcement purposes. Failure to provide the information may result in denial of access
to BPA or contractor facilities and personnel.
1. Name of Visitor/Assignee
First Name:

Middle:

Last:

2. Visit Determination Information
Citizenship:

Country of Employer:

Type of Request (check one):

Visit (less than 30 days)

Assignment (30 consecutive days or more)

Extension of an Assignment

3. Biographical Information
Gender:

Female

Is Visitor currently in U.S.?

Male

Country of Citizenship:

Date of Birth (mm/dd/yyyy):

Country of Birth:

City of Birth:

Additional Biographical Information:

(If known, FN will complete this section completely)

Current U.S. Address:

City:

Street (1):

State:

Street (2):

Zip Code:

Permanent Address:

City:

Street (1):

State:

Street (2):

Zip Code:

4. Employer Information
Institution or Company Name:

Phone Number:

Street (1):

Fax Number:

Street (2):

Email Address:

City:

State/Providence:

Zip Code:

Country of Employer:

Title or Position and Duties:

5. Visa Information

6. Passport Information

Visa Number:
Visa Type:

Passport Number:
Visitor

Exp. Date (mm/dd/yyyy):

Student/Exchange Visitor

All Other

Country of Issue:
Exp. Date (mm/dd/yyyy):

OFFICIAL USE ONLY
May be exempt from public release under the Freedom of Information
Act (5 U.S.C. 552), exemption number and category: ______________
BPA review required before public release
Name/Org: ______________________________ Date: ___________

Yes

No

BPA F 5632.08e
(08-18)
Page 2 of 3

U.S. DEPARTMENT OF ENERGY
BONNEVILLE POWER ADMINISTRATION
UNCLASSIFIED VISITS AND ASSIGNMENTS - FOREIGN NATIONALS
REGISTRATION (SHORT FORM)

OMB

Privacy Notice: The information on this form is requested to determine access to facilities operated by the Bonneville Power
Administration (BPA) or its contractors. Access to the information collected will be provided to the Department of Energy, and may be
provided to appropriate Federal agencies for law enforcement purposes. Failure to provide the information may result in denial of access
to BPA or contractor facilities and personnel.

7. Place of Work (if different from Employer)
Company Name:

Phone Number: Fax
Number:

Street (1):

Email Address:

Street (2):

State:

City:

Country of Employer:

Zip Code:
Title or Position and Duties:

Interpreter Needed?

✔

Yes

Business Type conducted by Employer:

No

Field of Research:

Educational Background:

8. Host Information
Host’s First Name:

Middle:

Last:

Host’s Citizenship:

Phone:

Mobile
Phone

Does the host have a clearance?

Yes

No

9. Visit Information
Desired End Date (mm/dd/yyyy):

Desired Start Date (mm/dd/yyyy):
Subject(s): (Choose from the drop-down menus)

3092-Fire Safety Inspection/Maintenance 3252-Virus Detection

701-Environmental Mgmt

Description of Visit/Assignment, including specific activities or involvement:

Purpose of visit (Choose from the drop-down menu):

Car Pool

Is the assignment for intermittent access periods? (Example: 2
rd

days one week, 3 days the next week, 1 day on 3 week=6 days)

Yes

No

Number of Days On site:

Will there be interactions with individuals with Security Clearances? (Secret or Top Secret clearances)

Yes

List individuals:
First Name:

Middle:

Last:

First Name:

Middle:

Last:

Is this Visit for Employment?

Yes

No

Official Use Only

No

BPA F 5632.08e
(08-18)
Page 3 of 3

U.S. DEPARTMENT OF ENERGY
BONNEVILLE POWER ADMINISTRATION
UNCLASSIFIED VISITS AND ASSIGNMENTS - FOREIGN NATIONALS
REGISTRATION (SHORT FORM)

OMB

Privacy Notice: The information on this form is requested to determine access to facilities operated by the Bonneville Power
Administration (BPA) or its contractors. Access to the information collected will be provided to the Department of Energy, and may be
provided to appropriate Federal agencies for law enforcement purposes. Failure to provide the information may result in denial of access
to BPA or contractor facilities and personnel.

List Buildings and Rooms to be accessed:
Building:

Room:

Type:

Building:

Room:

Type:

Building:

Room:

Type:

Cost to DOE/BPA:

DOE/BPA Mission(s) that will be advanced by this Visit/Assignment:

Will Visitor/Assignee be granted computer access?
If granted computer access, is the access on-site or off-site?

Yes

✔

On

No
✔

Off

List hardware and software to which access is granted:

10. Remarks/Comments (or additional information that did not fit above)

Paperwork Reduction Act Burden Disclosure Statement
This data is being collected to the security and safety of BPA employees, contractors, and facilities. The data you supply will be used by security
personnel to document all foreign nationals' purpose and dates of their intended visit/assignment. Public reporting burden for this collection
of information is estimated to average .21 hours per response, including the time for reviewing instructions, searching exiting data
sources, gathering and maintaining that data needed, and completing and reviewing the collection of information. Send comments regarding
this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Office of the
Chief Information Officer, Enterprise Policy Development & Implementation Office, IM-22, Paperwork Reduction Project (enter OMB control
number), U.S. Department of Energy, 1000 Independence Ave SW, Washington, DC, 20585-1290; and to the Office of Management and
Budget (OMB), OIRA, Paperwork Reduction Project (enter OMB control number), Washington, DC 20503.
Notwithstanding any other provision 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 Paperwork Reduction Act unless that collection of information
displays a currently valid OMB control number.
The Paperwork Reduction Act (PRA) of 1995 requires each Federal agency to seek and obtain approval from the Office of Management and Budget
(OMB) before undertaking a collection of information directed to 10 or more persons of the general public, including persons involved in or supporting
the operations of Government-owned, contractor-operated facilities.

Official Use Only