Request For Unclassified Foreign National Access Page 2
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7NETL F 142.1-1
U.S. DEPARTMENT OF ENERGY
Revised: 11/13/2013
Reviewed: 11/13/2013
REQUEST FOR UNCLASSIFIED
(Page 2)
FOREIGN NATIONAL ACCESS
INTRODUCTION – Once completed and saved, entries on page 2 of this document/form (NETL F 142.1-1) are considered Official Use Only (OUO)
information subject to the PRIVACY ACT. This document/form is to be initiated by an NETL or NETL site-support contract employee officially
designated as host or alternate host of a foreign national (FN) and is required for all access periods regardless of country of origin. Information on the
completed document/form will be used during the NETL FN access request, review, and approval process. For all Open to the Public Event exemption
requests, see Section J, page 7. If requesting Section A – Personal Data information directly from the FN, use or transmit NETL F 142.1-1A and the
accompanying OUO Cover Sheet instead. See Section K, page 7. DO NOT accept or transmit either completed form without an OUO Cover Sheet.
Start Date
End Date
Date Request Submitted
(MM/DD/YYYY)
(MM/DD/YYYY)
(MM/DD/YYYY)
09/24/2014
09/25/2014
Open to the Public Event Name
CCSI Industry Advisory Board Program Review Meeting
Visitor Number (DOE Use Only)
Request Number (DOE Use Only)
SECTION A – PERSONAL DATA
1a. Name of Foreign National – Last, First, Middle
1b. Alias (If Used)
2. Gender
3.
Date of Birth
(MM/DD/YYYY) (See
(See Section H)
Section H)
□ Male
□ Female
4.
Place of Birth (City, Country)
5.
Citizenship (List all countries)
6a. Lawful Permanent
7a. Visa Type
8a. Passport Number
9.
Social Security Account Number
Resident (LPR)?
(SSAN)
(See Section H)
□
Yes
□
No
7b. Visa Number/Control Number
8b. Passport Country of Issue
10. List other Identification
6b. LPR Card (I-551)
Documentation
(See Section H)
7c. Visa Expiration Date
8c. Passport Date of Issue
(MM/DD/YYYY)
(MM/DD/YYYY)
6c. LPR Card (I-551)
Visa Extension Date (DOE Use Only)
8d. Passport Expiration Date
(MM/DD/YYYY)
Expiration Date
(MM/DD/YYYY)
Passport Extension Date (DOE Use Only)
11a. Name and Address of Employer at Start of Access Period
11b. Name and Address of Place of Work (If different from 11a.)
Name
Name
Street
Street
City
State/Province
City
State/Province
Zip/Postal Code
Country
Zip/Postal Code
Country
12. Employment Title/Position, or Description of Duties during Access Period
13. Employer Type of Business or Organization (e.g., Government, company, laboratory, university, etc.)
14. Work Telephone and Facsimile (Fax) Number
15. Cell Telephone Number/Other Telephone Number
16. Email Address(es)
17. Educational Background (F1 or J1 Visa holders only). Include university/college training with degrees and month/year conferred.
(See Section H)
18. Field of Research (List topics)
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