Appendix B to Part 514--Exchange Visitor Program Services,
Exchange-Visitor Program Application
Form Approved OMB________________________________________________
Serial No._______________________________________________________
1. Name and Address of Sponsoring Organization
2. Name and Title of Responsible Officer
Telephone Number
3. Name and Title of Alternate Responsible Officer
Telephone Number
4. Type of Application
(check one)
New _______  Re-Apply _______ Re-Designation_______
Section I--Program Participant Data (For Definition & Length of
           Stay See 22 CFR ___)
5. Participation by Category (indicate total no. and approximate
   duration of stay in each category)
A. Student_______________________________________________________
B. Teacher_______________________________________________________
C. Professor_____________________________________________________
D. Researcher____________________________________________________
E. Short-term Scholar____________________________________________
F. Specialist____________________________________________________
G. Trainee_______________________________________________________
     1. Specialty________________________________________________
     2. Nonspecialty_____________________________________________
H. Int'l Visitor_________________________________________________
I. Gov't Visitor_________________________________________________
J. Physicians____________________________________________________
K. Camp Counselors_______________________________________________
L. Summer/Work/Travel____________________________________________
6. Method Of Selection
7. Arrangements for Financial Support of Exchange Visitor while
   in the U.S.
Section II--Program Data
8. Outline of Proposed Activities (If training, See Reverse)
9. Arrangements for Supervision and Direction
10.  Purpose of Objective________________________________________
11. Role of other Organizations Associated with Program (if any)
Section III--Certification
12. Citizenship Certification of Organization and Responsible
Officer (see reverse)
13. I certify that information given in this application is true
to the best of my knowledge and belief and that I have completed
appropriate information on reverse of this form.
Signature of Responsible Officer
Instructions for All Programs
If additional space is needed in supplying answers to any
questions, please use continuation sheets on plain white paper.
1-3.  Names and addresses of organization and telephone numbers.
4.    Select type of application.
5.    Select appropriate categories (see 22 CFR prior to filling 
      out this data).
6-7.  Complete information on program sponsor.
8-11. Complete information on program.
IF TRAINING PROGRAM, identify appropriate fields: 01--Arts &
Culture; 02--Information Media and Communications; 03--Education;
04--Business and Commercial; 05--Banking and Financial;
06--Aviation; 07--Science, Mechanical and Industrial;
08--Construction and Building Trades; 09--Agricultural;
10--Public Administration; 11--Training, Other
Reapplication and Redesignation:
If your organization is making reapplication as an exchange
visitor program, or applying for redesignation under 22 CFR __,
please certify to the following:
I hereby certify that as an officer of the organization making
application for an exchange program under 22 CFR __ or 22 CFR __
that the following documents which have been submitted to the
United States Information Agency, Exchange Visitor Program
Services, remain in effect and not altered in any way:
(1) Legal status as a corporation such as Articles of
Incorporation and By Laws. Provide dates and state of both:____
(2) Accreditation. Provide date, type of accreditation, and State
of accreditation:______________________________________________
(3) Evidence of Licensure. Provide date, type of license, and
state of licensure:____________________________________________.
(4) Authorization of governing body authorizing application.
Please provide date of such authorization and authorizing
(5) Activities in which the organization has been engaged have
not changed since application dated:___________________________.
(6) Citizenship. Provide the date of compliance with citizenship
requirements:_________________.  If citizenship compliance is not
current, please complete the following:
Organization: I hereby certify that I am an officer of
_________________________________________________ with the title
of _____________________________________; that I am authorized by
the (Board of Directors, Trustees, etc.) to sign this
certification and bind ____________________; and that a true copy
certified by the (Board of Directors, Trustees, etc.) of such
authorization is attached. I further certify that
________________________ is a citizen of the United States as
that term is defined at 22 CFR 514.1.
Responsible Officer or Alternate Responsible Officer: I hereby
certify that I am the responsible officer (or alternate
responsible officer) for ____________________________________,
and that I am a citizen of the United States (or a person
lawfully admitted to the United States for permanent residence.
_______________________ agrees that my inability to substantiate
my citizenship or status as a permanent resident will result in
the immediate withdrawal of its designation and immediate return
of or accounting for all IAP-66 forms transferred to it.
Certification as to (1)-(6) Requirements:
I understand that false certification may subject me to criminal
prosecution under 18 U.S.C. 1001, which reads: "Whoever, in any
matter within the jurisdiction of any department or agency of the
United States knowingly and willfully falsifies, conceals or
covers up by any trick, scheme or device a material fact or makes
any false writing or document knowing the same to contain any
false, fictitious or fraudulent statement or entry, shall be
fined not more than $10,000 or imprisoned not more than five
years, or both."
Signed in ink by
Subscribed and sworn to before me this ___ day of ________, 19__.
Notary Public
USIA Use Only
Type of
Subtype if
No. Forms
Please return form to:
Exchange Visitor Program Services-GC/V, United States Information
Agency, Washington, DC 20547
Note: Public reporting burden for this collection of information
(Paperwork Reduction Project: OMB No. 3116-0011) is estimated to
average __ minutes/hours per response, including time for
reviewing instructions, researching existing data sources,
gathering and maintaining the data needed, and completing and
reviewing the collection of information. Send comments regarding
this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to
USIA Clearance Officer, M/ASP, U.S. Information Agency, 301 4th
Street, SW., Washington, DC 20547; and to the Office of
Information and Regulatory Affairs, Office of Management and
Budget, Washington, DC 20503.