Dd Form 2859 - Foreign Activities Questionnaire Page 2
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2FOREIGN ACTIVITIES QUESTIONNAIRE (Continued)
1. NAME (Last, First, Middle Initial)
2. COMMITTEE
3. DAYTIME TELEPHONE NUMBER (Include Area Code)
4. MAILING ADDRESS (Include ZIP Code)
5. E-MAIL ADDRESS (Optional)
6. Describe any activities you are currently undertaking, or expect to undertake, during your tenure on a Federal advisory
committee, involving a foreign government, including a foreign public university or government-owned corporation. Such
activities include consulting work, receipt of grants or contracts (directly or through your domestic employer), faculty
appointments, lectureships, or the holding of an office, title, or position.
IF NONE, X HERE.
7. If any activity described above is with a foreign public university and consists of a faculty appointment, describe whether
the university is independent of the foreign government with respect to decisions regarding the terms and conditions of faculty
employment. (You may have to consult with the foreign university to obtain such information.)
8. Describe any tangible or intangible gift, including travel reimbursement or other items of value, that you anticipate that you,
your spouse, or your dependent child will receive from a foreign government during your tenure on a Federal advisory
committee.
IF NONE, X HERE.
9. SIGNATURE OF REPORTING INDIVIDUAL
10. DATE (YYYYMMDD)
DD FORM 2859 (BACK), JUL 2005
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