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) _________________________________________________________________ _________________________________________________________________
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 body:__________________________________________________________.
(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 program:_________________________________________________________
Subtype if applicable:______________________________________________________
No. Forms IAP-66:__________________________________________________________
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.