Appendix B to Part 62 - Exchange Visitor Program Services, Exchange-Visitor Program Application

Link to an amendment published at 79 FR 60317, October 6, 2014.

Form Approved OMB

Serial No.

 

 

 

 

 

 

Re-Designation

Section I—Program Participant Data (For Definition & Length of Stay See 22 CFR ___)

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 Cnslr

L. Sumr/Wk/Trvl

 

 

 

Section II—Program Data

 

 

 

 

Section III—Certification

 

 

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 Department of State, 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 (Name)

Title

Department of State Use Only

Type of program:

Subtype if applicable:

No. Forms IAP-66:

Categories:

Please return form to:

Exchange Visitor Program Services-GC/V, Department of State, 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 Department of State Clearance Officer, M/ASP, Department of State, 301 4th Street, SW., Washington, DC 20547; and to the Office of Information and Regulatory Affairs, Office of Management and Budget, Washington, DC 20503.