Visitor/Assignee:
*First Name: / Middle: / *Last:
*Gender (select one): Male o Female o / Is Visitor currently in the US?: Yes o No o
*Permanent Resident Alien: Yes o No o
*Country of Citizenship: / *Date of Birth (mm/dd/yyyy):
*Country of Birth: / *City of Birth:
Interpreter Needed?: Yes o No o
Business Type conducted by Employer:
Educational Background:
Field of Research:
Employer Information
*Institution or Company Name:
Street (1):
Street (2):
City: / State:
*Country of Employer:
Zip Code: / Phone Number:
Fax Number: / E-mail Address:
Place of Work (if different from Employer)
*Institution or Company Name:
*Title or Position and Duties:
Street (1):
Street (2):
City: / State:
*Country of Employer:
Zip Code: / Phone Number:
Fax Number: / E-mail Address:
* denotes required information 2 of 4 pages
AliasesFirst Name: / Middle: / Last:
First Name: / Middle: / Last:
First Name: / Middle: / Last:
Visa Information / Passport Information
* Visa Number: / * Passport Number:
* Visa Type: / * Country of Issue:
* Exp. Date(mm/yy): / * Exp. Date(mm/yy):
Current U.S. Address
Street (1): / Street (2):
City: / State: / Zip Code:
Permanent Address
Street (1): / Street (2):
City: / State:
Country: / Zip Code:
UFV&A Request Information/Long Format
*Facility to be visited: / Waste Isolation Pilot PlantType of Request: Visit n Assignment o Off-site o
*Request Date: / *Desired Start Date: / *Desired End Date:
*Purpose of Visit: / To learn more about WIPP
*Will Sensitive Subjects be discussed?: / Yes o No n
*Is this a High Level Protocol Visit?: / Yes o No n
*Select the Security Area Type at the Facility: WIPP
Non-Security Area o Property Protection Area n Limited Area o
MAA o Exclusion Area o SCIF o
Remarks/Comments (or additional information that did not fit above):
* denotes required information 2 of 4 pages
Host’s First Name: / TBD / Middle: / *Last:*Host’s Citizenship: / *Phone:
*Does the Host have a clearance? / Yes þ No n
International Agreement Code: / NA
*HDE Code: / EM-23
Department/Division to be Visited: / Carlsbad Field Office – Waste Isolation Pilot Plant
*Justification of visit/assignment including specific activities or involvement:
Enhance the understanding of the WIPP repository concepts and transportation
*Subjects (may list more than one): / Waste management, transportation and disposal
*Is the assignment for intermittent access periods?: / Yes o No n
Number of Days On-Site: / 1 / Is this Visit/Assignment for Employment Purposes? Yes o No n
Will there be interactions with Individuals with Security Clearances? / Yes o No n
List Individuals:
First Name: / Middle: / Last:
First Name: / Middle: / Last:
First Name: / Middle: / Last:
*List Buildings and Rooms to be accessed:
Building: / G&S / SWB / Room: / Type:
Building: / WHB / CH Bay / Room: / Type:
Building: / Support / Underground / Room: / Type:
*Certification of DOE Mission: / Enhance understanding of waste isolation and disposal
*Anticipated benefits to DOE Programs: / Promote the WIPP internationally.
*DOE Contact
First Name: / Dennis / Middle: / S. / *Last: / Hurtt
*Contact’s Phone: / 505 234-7327 / *Cost to DOE: / 0
*Will Visit/Assignment include transfer of Technology?: Yes o No n Unknown o
If there is to be technology transferred, describe: / NA
*Export License Required?: / Yes o No n Unknown o
Date Export License Requested (mm/dd/yyyy): / License D Number: / D
Date Export License Granted (mm/dd/yyyy): / License D Number: / Z
*Will Visitor/Assignee be granted computer access? / Yes o No n
If granted computer access, is the access on-site or off-site? / On-Site o Off-Site o
List any networks to which access is granted:
Remarks/Comments (or additional information that did not fit above):
Name or requesting official or contractor / Name of local/headquarters approving officials
Susan R. Scott / Dave C. Moody
Title and organization of requesting officer / Title and organization of local/headquarters approving
Manager, Communication
Washington TRU Solutions, LLC / Manager, Carlsbad Field Office
Signature of requesting official or contractor / Signature of local/headquarters approving official
Date signed (mm/dd/yyyy) / Date signed (mm/dd/yyyy)
* denotes required information 2 of 4 pages