Form Ds-2003 (Formerly Dsp-110) - Notification Of Appointment Of Foreign Diplomatic Officer And Career Consular Officer Page 2

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20. ALL PREVIOUS ASSIGNMENTS WITHIN THE UNITED STATES (If not listed in item 21 below, including study and training)

(List To/From (mm-yyyy))

21. ALL ASSIGNMENTS/POSITIONS/ACADEMIC STUDIES/OTHER ACTIVITIES WITHIN PAST FIVE YEARS (Dates, nature of activity, and location -

beginning with most recent) (List To/From (mm-yyyy))

22. FAMILY MEMBERS Residing in household in the United States (Use DS-2007 continuation sheet if necessary; Staple to this form)

(a) SURNAME (Last)

(b) GIVEN (First)

(f) MAIDEN

(g) OTHER

(d) PREFIX

(e) SUFFIX

(h) RELATIONSHIP

MALE

FEMALE

NO.

If No, give correct sequence:

Is the correct sequence for printing name a, b, c, e?

YES

ABBREVIATED

NAME:

Please indicate how name should appear on documents (identification cards, etc.) Last name first.

DATE OF BIRTH (mm/dd/yyyy)

PLACE OF BIRTH (City, Country)

CITIZENSHIP

VISA STATUS (Attach copies)

23. PLEASE INDICATE IF REQUESTING IDENTIFICATION CARDS FOR DEPENDENT:

YES

NO.

Attach envelope with 4 recent

Intentional provision of false information on this form violates United States law (Title 18 U.S. Code, Section 1001)

photographs of principal, 5 for

and will be considered a violation of the international legal obligation of foreign missions and their personnel to respect

Ambassador

the laws of the receiving state (Vienna Convention on Diplomatic Relations, 1961, Article 41; Vienna Convention on

2" x 2"

Consular Relations, 1963, Article 55).

Color

Attach 3 photographs for

ANY CHANGES IN THIS INFORMATION MUST BE REPORTED

spouses of diplomats, 4 for

IMMEDIATELY TO THE OFFICE OF PROTOCOL (USE FORM DS-2006,

spouse of Ambassador

NOTIFICATION OF CHANGE)

Attach 2 photographs for each

SIGNATURE OF APPLICANT

DATE (mm-dd-yyyy)

dependent eligible for an

identification card.

(Embassy Seal)

TYPED NAME & SIGNATURE OF CHIEF OF MISSION

DATE (mm-dd-yyyy)

Print name and mission on

OR AUTHORIZED DEPUTY

back of each photo

PRIVACY ACTS and PAPERWORK REDUCTION ACT STATEMENTS

The Privacy Act of 1974, as amended, 5 U.S.C. 552a, contains provisions regarding the maintenance, collection, use, and dissemination of

information about United States citizens and aliens lawfully admitted for permanent residence in the United States. The following information is

provided in accordance with subsection (e)(3) of the Privacy Act.

AUTHORITIES:

Vienna Convention on Diplomatic Relations of 1961; Vienna Convention on Consular Relations of 1963; Diplomatic Relations Act (22 U.S.C.

254a-e); International Organizations Immunities Act (22 U.S.C. 288e(a)).

PURPOSE:

The principal purpose for the collection of this information is to implement various provisions of the above-cited authorities which are predicated upon

acceptance by the U.S. Department of State.

ROUTINE USES:

The principal users of this information are offices within the U.S. Department of State, including but not limited to, the Office of Protocol, the

Office of Foreign Missions, and the Office of Visa Services. In response to inquiries from law enforcement agencies, the Office of Protocol may confirm status as

recognized by the U.S. Department of State. Information may also be provided to other government agencies having statutory or other lawful authority to maintain

such information. Certain information specifically related to the operation and activities of the Executive Council on Foreign Diplomacy or The Hospitality and

Information Service (THIS) may be provided to those organizations. Names of the members of the diplomatic staff, office addresses, titles, and names of spouses are

published quarterly in the Diplomatic List, U.S. Department of State Publication 10424. Names of Consular Officers, titles, and office addresses are published

semiannually in Foreign Consular Offices in the United States, U.S. Department of State Publication 10277.

Submission of these forms is mandatory. Failure to provide any of the requested information may prevent acceptance and the extension of benefits to

principals or family members as provided in the above-cited authorities.

*Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time required for searching existing data

sources, gathering the necessary data, providing the information required, and reviewing the final collection. In accordance with 5 CFR 1320.5(b), persons are not

required to respond to the collection of this information unless this form displays a currently valid OMB control number. Send comments on the accuracy of this

estimate of the burden and recommendations for reducing it to: U.S. Department of State (A/RPS/DIR) Washington, DC 20520.

DS-2003

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