User Information Form
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1SSRL RDB ID No. :
SLAC System ID No.:
SSRL User Information Form
Date Today: ____________________
Beam Line-Start Date: ____________
____________________________________________________________________________________________
Name:
First
Middle
Last
Suffix
Email : ______________________________________________________________________________________________________
Institution/Company: __________________________________________________________________________________________
Department: _________________________________________________________________________________________________
Street Address: _______________________________________________________________________Mail Code : _____________
City / Province: ____________________________________ State: _____________________________________________________
Country: __________________________________________ Zip Code: _________________________________________________
Work Phone: __________________________Lab Number: __________________ Home Number: ___________________________
Fax Number: ______________________________________ Cell/ Pager: ________________________________________________
Emergency Contact Person: _______________________________________Phone Number: _______________________________
:
:
YEAR of Birth
Gender
Male:
Female:
(XXXX)
_______________________________________________
Race/Ethnicity:
American Indian/Alaskan Native
Asian/Pacific Islander
African American
Hispanic
White or Caucasian
Information Not Provided
Any Other Names Used : ________________________________________Subscribe to SSRL Headlines Newsletter :
Yes
No
Spokesperson: ______________________________________________Proposal No.: ___________Beam Line: ________________
Relationship to SSRL
(please select all that apply):
General User
Participating/Partner Research Team (PRT)
Staff
Vendor / Contractor
Visitor
Other (specify) : __________________________________________________________________________________________________________
Job Classification:
Undergraduate
Graduate Student
Postdoctoral Fellow
Scientific / Professional Staff
Faculty
Self Employed
Retired/ Emeritus
Other (specify) : __________________________________________________________________________________________________________
Highest Degree Earned and Year Completed :
High School_____
AA____
AS_____
BA_____
BS_____
EE_____
JD_____
MA_____
MD_____
MS_____
PhD_____
DPhil _____
Citizen of
(Name of Country):_________________________________________________________________________________________________
If Not U.S. Citizen, Provide Country of Birth:_______________________________________________________________________
(For all non U.S. citizens, annually we must verify passport, visa and relevant USCIS documentation, including: I-94, I-20, I-797, DS-2019/IAP-66.)
Passport, Expiration Date, Country of Issue: _______________________________________________________
________
Verified by:
Visa Type, Expiration Date; Expiration Date of Relevant USCIS Documents (I-94, DS-2019/IAP-66, I-20, I-797):
________________________________________________________________________________________________________________________
___________
Verified by:
If Permanent U.S. Resident Alien/Green Card, please provide Expiration Date
:_________________
________
(Mo / Da / Yr)
Verified by:
Is this your first visit to SSRL?
Yes
No
URA Office Use Only
We recognize the time and effort needed to comply with this new requirement, and we appreciate your full cooperation with this effort.
User Research Administration
Stanford Synchrotron Radiation Laboratory (SSRL)
2575 Sand Hill Rd, MS 99, Menlo Park, CA 94025
jackie@slac.stanford.edu, TEL 650-926-2079/FAX 650-926-4499
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