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Individuals submitting or transmitting their personally identifiable information (PII) or other sensitive data to DARPA should apply appropriate security protocols to safeguard their privacy. Once received, DARPA secures PII or sensitive personal data from unauthorized access, use or disclosure in a controlled, secure environment. The Privacy Act Statement disclosure below includes important information. Please read it carefully.

PRIVACY ACT STATEMENT

AUTHORITY: 5 U.S.C. 301; 40 U.S.C. 1441; 41 C.F.R. 102-81.10 and 102-81.15; DoDD 1000.25; DoD 5200.08-R; DoDD 5200.27; DoDD 5205.07; DoDD 5230.20; DoD 5400.11-R; OMB M-17-12 (modifying and/or replacing, as appropriate, OMB Memorandums M-06-15 and M-07-16); and, E.O. 12977.

PURPOSES: Personally identifiable information (PII) is necessary to maintain the security of personnel, property, and equipment and is only used to: a) determine and verify identity, eligibility, and/or status of individuals who have applied for, sought, been considered for, attempted, and/or obtained access; and, b) for control of badges issued for physical and logical access. DARPA will not create records of PII and neither owns nor maintains Privacy Act systems of record. The applicable system of records is the DoD Foreign Visits System, and the applicable system of records notice is DUSDP08, available from the Defense Privacy, Civil Liberties, and Transparency Division at http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570593/dusdp-08/.

ROUTINE USES: DoD "Blanket Routine Uses" apply (see http://dpcld.defense.gov/Privacy/SORNsIndex/Blanket-Routine-Uses/). Requested information will be used by, and only disclosed to, DARPA personnel, contractor employees, or other agents who require the information within other government agencies as necessary to determine if access to a DARPA facility or program should be granted. DARPA may also share the information with other agencies as necessary to determine if adverse information exists on the individual seeking access to a DARPA facility or program.

DISCLOSURE: Furnishing this information (including your Passport information and Social Security Number if applicable) is voluntary. However, failure to furnish the requested information may delay or prevent your requested access to a DARPA facility or program.

PLEASE CHECK THE BOX FOR THE BELOW STATEMENTS PRIOR TO COMPLETING THE FORM.
THIS FORM WILL NOT BE PROCESSED WITHOUT ACKNOWLEDGED AGREEMENT.

I certify that I am not representing a foreign government (non-U.S.) in an official capacity during this visit.

I understand that a non-U.S. citizen representing a foreign government (non-U.S.) in an official capacity is required to coordinate with their Embassy and complete an official Foreign Visit Request. These visit requests are received by DARPA thru the Foreign Visit Request System.

I understand that as a visiting foreign national I am required to present my passport, or my Permanent Resident Card as a U.S. Permanent Resident.

Additional questions regarding foreign national visits to DARPA, or its events, may be sent to your DARPA Point of Contact the Security and Intelligence Directorate International Security staff at SIDInternationalsecurity@darpa.mil.

Visitor Data

First Name *

Middle Name

Last Name *

Country of Birth *

City Of Birth *

Date Of Birth *

Current Nationality/Citizenship *

Dual Citizenship? *

Yes No

If Yes, select second country *

U.S. Permanent Resident? *

Yes No

If Yes, Immigrant Alien Number *

Passport Number *

Passport Country Issued *

U.S. Social Security Number (if any)

Visa Type

Visa Expiration Date

Company/ Organization/ University

Name *

Country of Ownership *

Address *

City *

State *

Phone *

Position *

Visit Information

DARPA POC *

Date Of Visit *

EndDate Of Visit *

Meeting Location *

DARPA Offsite

Classification Level of Discussion *

Purpose Of Visit/Topics for Discussion *

Comments

DARPA Form 60, DEC 2017

Previous Edition Obsolete

U.S. Permanent Resident and Foreign National Visit Request

PRIVACY ACT STATEMENT

Visitor Data

Company/ Organization/ University

Visit Information