(Please TYPE OR PRINT)

First Name: ____________________________________

Middle Name or Initial or NMI (No Middle Initial): ____________________

Last (or Family) Name: _____________________

Gender: Male _____ Female: _____

U.S. Social Security Number (if applicable): ____________________

Are you a Permanent Resident Alien (Greencard Holder): No ___ Yes ___

If Yes, Number: _____________________; Expiration Date: _____________

Date Issued (mm/dd/yyyy): _________________

Expiration Date (mm/dd/yyyy): ________________

Country of Citizenship: ______________________

Date of Birth: Month_____________ Day_______ Year ________

Country of Birth: __________________ City of Birth: ____________________

Permanent Home Address: _______________________________________________________________

Place & Date of Entry into U.S.:

Current U.S. Address (if applicable):

NASA Installation to be visited: ________________________

NASA Point of Contact: _____________________________

Planned dates of visit (inclusive): ____________________________________

Affiliation or Employer:

Institution or Company Name: _________________________________

Street Address: ____________________________________________

City: _____________________________________________________

State/Country: _____________________

Zip Code: ______________

Title or Position and Duties: __________________________________________________________

Phone Number: _______________________

Fax Number: _______________________

E-mail Address: _______________________

U.S. Visa Information:

U.S. Visa Type (e.g.; B-1/B-2, H-1B, J-1, F-1, etc)_________________

Visa Expiration Date (mm/dd/yyyy): _________________

If J-1, name of U.S. Program Sponsor (attach IAP-66): _______________

Passport Information:

Country of Issue: _________________

Passport Number: ________________

Passport Expiration Date (mm/dd/yyyy): _________________