UNCLEARED VISIT REQUEST FORM FOR ITAR CERTIFICATION

 

To be completed by visitor Facility Security Officer (FSO)

Name of Company/Institution                                                              Company/Institution Phone Number

 

 

 

Company/Institution Physical Address (PO Boxes not acceptable)

 

 

 

Full Legal Name (First, MI & Last)

Official Photo ID Type

State Issued

ID Number

Expiration Date (mm/dd/yy)

Place of Birth

City, State, Country

Citizenship

Verified

Example:

John A. Doe

Drivers License

AZ

123456789

01/01/09

Phoenix, AZ, USA

USA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

To be completed by visitor Facility Security Officer (FSO)

I hereby certify that the above employee(s) is/are U.S. persons as defined in the International Traffic in Arms Regulations (ITAR) Section 120.15 which includes U.S. citizen(s) or lawful permanent resident(s) of the United States and protected individuals.

 

Approval signature of visitor company official certifying U.S. person status.

 

 

Printed name of visitor company official certifying U.S. person status.

 

Title of visitor company official certifying U.S. person status.

 

 

Email of visitor company official certifying U.S. person status.

 

Date:

 

Phone:

 

To be completed by ASU Facility Security Officer (FSO)

 

Requestor Name:                                                                                Department:

Reason for Visit:

FSO Approval:      Yes    No           Signature:                                                                Date:

 

FAX completed form to ASU Office of Research Integrity and Assurance; Attn: Sheryl Trexler  480-965-7772