Appendix A to Part 514--Certification of Responsible Officers and
Sponsors
In accordance with the requirement at Sec. 514.5(c)(6), the text
of the certifications shall read as follows:
1. Responsible Officers and Alternate Responsible Officers
I hereby certify that I am the responsible officer (or alternate
responsible officer, specify) for exchange visitor program number
___________, and that I am a United States citizen or permanent
resident. I understand that the United States Information Agency
may request supporting documentation as to my citizenship or
permanent residence at any time and that I must supply such
documentation when and as requested. (Name of organization)
agrees that my inability to substantiate the representation of
citizenship or permanent residence made in this certification
will result in the immediate withdrawal of its designation and
the immediate return of or accounting for all Forms IAP-66
transferred to it.
Signed in ink by
_________________________________________________________________
(Name)
_________________________________________________________________
(Title)
Witness:_________________________________________________________
This __________ day of _________________, 19____. Subscribed and
sworn to before me this __________ day of __________, 19____.
_________________________________________________________________
Notary Public
2. Sponsors.
I hereby certify that I am the chief executive officer of (Name
of Organization) with the title of (specify); that I am
authorized to sign this certification and bind (Name of
Organization). I further certify that (Name of Organization) is a
citizen of the United States as that term is defined at 22 CFR
Sec. 514.2. (Name of Organization) agrees that inability to
substantiate the representation of citizenship made in this
certification will result in the immediate withdrawal of its
designation and the immediate return of or accounting for all
Forms IAP-66 transferred to it.
Signed in ink by
_________________________________________________________________
(Name)
_________________________________________________________________
(Title)
Attestation/Witness:_____________________________________________
This ___________day of _________, 19____. Subscribed and sworn to
before me this ______ day of ____________, 19____.
_________________________________________________________________
Notary Public