Form DS-3036 Application for Designation, Redesignation and/or Amendm

INSTRUCTIONS FOR NEW APPLICATION
If additional space is needed for answering any questions, use continuation sheets or plain white paper.
1-3.
Name, 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 62.2 CFR 62.4 and 22 CFR
62.20-32)
6-10. Complete information on program and program sponsor.
IF APPLYING FOR EITHER THE INTERN OR TRAINEE CATEGORIES, identify the appropriate Occupational Category(ies):
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.

Certification. Citizenship for new applicants requires certification below.
CITIZENSHIP (22 CFR 62.2 and 5)

(a) Organization
I hereby certify that I am the Chief Executive Officer (or equivalent) 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 revocation of or accounting for all DS-2019 forms.
(b) Responsible Officer or Alternate Responsible Officer
Alternate Responsible Officer for this program and
Responsible
I hereby certify that I am the (Check one)
that I am a citizen of the United States (or a person lawfully admitted to the Unites States for permanent residence).
agrees that my inability
Name of organization
to substantiate my citizenship or status as a legal permanent resident will result in the immediate withdrawal of
its designation and the immediate revocation of or accounting for all DS-2019 forms.
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 (RO/ARO)
Chief Executive Officer (or equivalent)
PLEASE SEND CORRESPONDENCE TO:
U.S. Department of State
ECA/ECD/D, SA-44
Room 664
Washington, DC 20547-4406

DS-3036
11-2013

Instruction Page 1 of 1

U.S. Department of State

Application for Designation, Redesignation and/or Amendment

OMB APPROVAL NO. 1405-0147
EXPIRATION DATE:xx/xx/xxxx
ESTIMATED BURDEN:8 HOURS
*See Page 3

1. Name and Address of Sponsoring Organization

2. Name and Title of Responsible Officer

Telephone/Email Address

3. Name and Title of Alternate Responsible Officer

Telephone/Email Address

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

5. Participation by Category

SECTION I - PROGRAM PARTICIPANT DATA
(Indicate the total and approximate duration of participation in each category)

Type

Dur.

No.

Type

No.

Dur.

Type

No.

Dur.

Type

Alien Physician

Au Pair

Camp Counselor

Government Visitor

Intern

International Visitor

Professor

Research Scholar
Student: Secondary

Short-term Scholar

Specialist

Student: Col/Univ

Summer Work/Trvl

Teacher

Trainee

(check one)

No.

Dur.

(See Title 22 Code of Federal Regulations, Part 62)

SECTION II - PROGRAM DATA
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)

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. 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
11-2013

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U.S. Department of State

Private Sector Exchanges
Office of Designation
Application for Designation, 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 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 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 d
uties 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
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 revocation 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

PLEASE SEND CORRESPONDENCE TO:
U.S. Department of State
ECA/ECD/D, SA-44
Room 664
Washington, DC 20547-4406

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 8 hours 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: U.S. Department of State, ECA/ECD/D, SA-44, Room 664, Washington, DC 20547-4406.
DS-3036

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