Appendix D  Annual Report--Exchange Visitor Program Services
            (GC/V), United States Information Agency, Washington,
            DC 20547,(202-401-9810)
Exchange Visitor Program No. ________ Reporting Period _______ 
Provide Range of Forms IAP-66 Documents Covered by this Report
(_________-_________).
(a) STATISTICAL REPORT
(1) ACTIVITY BY CATEGORY
                                                         Number
     Professors                                          ______  
     
     Research Scholars                                   ______  
     
     Short-term Scholars                                 ______  
     Trainees                                            ______  
     Students (College and University)                   ______  
     
     Students (Practical Trainee)                        ______  
     
     Teachers                                            ______
     Students (Secondary)                                ______  
     
     Specialists                                         ______  
     
     Physicians                                          ______  
     
     International Visitors                              ______  
     
     Government Visitors                                 ______  
     
     Camp Counselors                                     ______  
     
                              
     Total                                               ______  
     
                                                        
(2) Forms IAP-66 Reconciliation
     (i)   Number of Forms IAP-66 voided or otherwise not used by
           participant ___________
     (ii)  Number of Forms IAP-66 issued for dependents ________
     (iii) Number of Forms IAP-66 currently on hand ____________
(b) PROGRAM EVALUATION
On a separate sheet, please provide a brief narrative report on
program activity, difficulties encountered and their resolution,
program transfers, anticipated growth and the proposed new
activity, cross-cultural activities, as well as the reciprocal
component of the program.
I, The Responsible Officer of the program indicated above,
certify that we have complied with the insurance requirement (22
CFR 514.14). I also certify that the information contained in
this report is complete and correct to the best of my knowledge
and belief.
_________________________________________________________________
Responsible Officer (signed)
Date________________
_________________________________________________________________
Name and address of sponsoring institution