INSTRUCTIONS FOR COMPLETING FORM DS-2004,
NOTIFICATION OF APPOINTMENT
OF FOREIGN GOVERNMENT EMPLOYEE
Please read all instructions before completing this form.
This form is to be completed for all employees of foreign missions except diplomatic and consular officers. All questions should be answered completely and accurately. If a question does not apply, please type N/A.
Any changes in the information provided on this form should be reported as soon as possible using the Notification of Change, Form DS-2006.
In the case of members of the administrative and technical and service staffs of embassies and consular employees and members of the service staff of consular posts, the United States does not extend privileges and immunities to persons unless documentation is provided to indicate that the sending state: (1) pays the cost of the employee's transportation to the U.S. from the employee's normal place of residence; (2) transfers the employee and his or her immediate family out of the United States within a specific time frame consistent with the sending state's transfer policy; and (3) pays the cost of the employee's transportation from the United States to the employee's normal place of residence or to the country of the employee's next assignment.
NOTE: It is important that all information provided to the Office of Protocol and the Office of Foreign Missions be consistent. Discrepancies, such as in the spelling of the name, the residence address, date of birth, etc., may delay processing applications for identification cards, tax exemption cards, drivers' licenses, and automobile registrations.
The instructions below are numbered to correspond to the numbered items on the form.
PLEASE TYPE ALL ANSWERS.
If employee is a U.S. citizen, the following items do not need to be completed: 8, 9, 10, 16, 17, 18, 20, 21, 22, (unless family member also is employed
by a foreign government or international organization), or 23.
1Enter the name of the Embassy or Mission submitting the form. Give telephone number and email address of office which can be contacted for further information, if necessary.
2Enter "X" in the box to indicate if the employee works at an embassy, consulate, miscellaneous foreign government office, or mission to an international organization, or is a personal or domestic employee of a foreign government official. For personal or domestic employee, check box corresponding to employer's status (e.g. Embassy, Consular).
3Enter the officer's full name in the order specified:
(a) surname; (b) given name;
(c) prefix such as Mr., Mrs., Ms., or Miss,
military rank, or title; (d) suffix, such as Jr. or Sr.; and (e) maiden name. Type "X" to indicate if
male or female.
NOTE: The abbreviated name, if used, will appear in all publications and documents issued by the U.S. Department of State.
Enter present nationality.
Enter employee's date of birth (mm-dd-yyyy).
Enter nationality at birth, even if the same as Number 4.
Enter employee's place of birth - city and country or state.
Enter"X" in box indicating type of passport, if any.*
Enter "X" in box indicating type of United States visa held in passport, or if permanent resident, give alien registration "A" number.
Enter date (mm-dd-yyyy), of arrival in the United States and port of entry.
Enter residence address (not duty address unless actually living and working at the same location), in the United States where employee currently resides. If temporary (hotel, etc.), use Form DS-2006 to notify the Department of State when officer moves to a permanent address.
DS-2004 |
Instruction page 1 of 2 |
11-2017 |
|
Enter the name, address, and telephone number of foreign mission |
22 |
consulate, or office where the employee will be assigned. NOTE: For domestic employees, give the name, Personal
Identification Number (PID), and title of the employer, and his/her complete office address.
Enter the name, address, and telephone number of the actual office or annex where the employee will be working, if different from Number 12. NOTE: For domestic employees, give the residence address where domestic duties will be performed.
NOTE: All addresses must be street addresses, including type, |
23 |
e.g. Street, Ave., Blvd., etc., not post office box numbers, and must include ZIP codes and telephone area codes.
Enter names of all eligible family members residing in the household in the United States, following the same format as in Number 3 above. Use Form DS-2007 for additional names. Give date of birth (mm-dd-yyyy), place of birth, (city country), current citizenship, and relationship to principle employee. Enter type of United States visa (A-1, B-2, etc.) currently held, or copy of Permanent Resident Alien card.
Enter "X" in appropriate boxes for an identification card. For embassy A&T staff (a) principals (who are not U.S. citizens,
permanent resident aliens or determined to be "permanently resident in the U.S.), (b) spouses (except U.S. citizens, spouses of persons
14Enter person's title or position, e.g. secretary, clerk, driver, cook, etc. Do not use any diplomatic or consular title reserved for officer.
15Enter the date (mm-dd-yyyy), employee assumed present official duties in the United States.
determined to be "permanently resident in" the U.S., and permanent
resident aliens), (c) dependents of persons determined to be "permanent resident aliens and dependents of person determined to be "permanent resident in" the U.S.)
who are unmarried children between 16 and 21 years who reside with their parents or are full-time students, or unmarried children
|
16 |
Enter the date (mm-yyyy) (approximate) that employee will terminate |
under 23 years who are full-time students (for students between 21 |
|
and 23 attach family status justification form), for consular officers |
|
|
duties in the United States.* |
|
|
|
|
|
only the consular employees and embassy service staff, principals |
17Enter name, title and (PID), if available, of the person the employee is replacing. Enter date (mm-yyyy), of termination of predecessor. If new position, so state. (Not applicable for domestic workers.)*
18If employee will serve in any official capacity other than that that listed in Number 14, enter position title and mission. Separate notification will be required.*
19If a family member (spouse or dependent) is or will be employed in the United States by a foreign government or international organization, please identify and indicate position or title, relationship and where the person is working. The person must be notified separately to the Office of Protocol using the appropriate form.
20If not listed in item 21, enter dates (mm-yyyy), nature of all previous assignments (including study and training) and place (city and state) in the United States. List To/From month/Year (mm-yyyy)*.
21Enter the dates (mm-yyyy), nature of employment (job title and employer), and place (city and country) of academic study or other activities for previous 5 years, starting from the most recent assignment prior to this one. List to/From--Month/Year (mm-yyyy). (NOTE: For Numbers, 20, 21, attach additional sheet, if necessary.)*
(who are not U.S. citizens, permanent resident aliens or determined to be "permanently resident in" the U.S.) unless the sending state
and the U.S. have entered into a bilateral agreement extending immunity to family members. Other employees and family members do not receive identification cards.* The employee must sign and date (mm-dd-yyyy) the form. In case of domestic employees, the official employers must also sign and date the form. The form must be signed and dated (mm-dd-yyyy) by the designated approving embassy official and the official embassy seal must
be affixed.
*Not required if person being registered is U.S. Citizen or Permanent Resident Alien
Submit forms and attachments to
U.S. Department of State
3507 International Place, NW
Washington, DC 20008-3034
ANY CHANGES IN THE INFORMATION PROVIDED ON THIS FORM SHOULD BE REPORTED AS SOON AS POSSIBLE USING THE NOTIFICATION OF CHANGE,
FORM DS-2006.
DS-2004 |
Instruction page 2 of 2 |
20.All previous foreign assignments within the United States. (If not listed in item 21 below, including study and training) (List To/From (mm-yyyy))
(Not applicable for International organizational personnel)
21.All assignments/positions/academic studies/other activities within past five years
(Dates, nature of activity, and location - beginning with most recent) (List To/From (mm-yyyy))
(Not applicable for International organizational personnel)
22.Family Members Residing in Household in The United States (Use DS-2007 continuation sheet if necessary; staple to this form.)
(a) Surname |
|
|
(b) Given Name |
|
|
|
|
|
|
(c) Prefix |
(d) Suffix |
(e) Maiden |
(f) Other |
(g) Relationship |
Date of Birth (mm-dd-yyyy)
Place of Birth (City, Country)
23. Please indicate if requesting identification cards |
|
|
|
For Employee: |
Yes |
No |
For Dependents: |
Yes |
No |
I understand that, if I am at present engaged in, or proposed to engage in, any activity on behalf of a foreign government as a public relations counsel, publicity agent, or information service employee, I must register with the Attorney General in accordance with 22 U.S.C. 612.
Intentional provision of false information on this form violates United States law (Title 18 U.S. Code, Section 1001) and will be considered a violation of the international legal obligation of foreign missions and their personnel to respect the laws of the receiving state (Vienna Convention on Diplomatic Relations, 1961, Article 41; Vienna Convention on Consular Relations, 1963, Article 55).
Signature of Applicant
Employer's Signature (For Private Domestic Employees)
Typed Name and Signature of Chief of Mission or Authorized Deputy
Date (mm-dd-yyyy)
Date (mm-dd-yyyy)
Date (mm-dd-yyyy)
PRIVACY ACT and PAPERWORK REDUCTION ACT STATEMENTS
The Privacy Act of 1974, as amended, 5 U.S.C. 552a, contains provisions regarding the maintenance, collection, use, and dissemination of information about United States citizens and aliens lawfully admitted for permanent residence in the United States. The following information is provided in accordance with subsection (e)(3) of the Privacy Act. AUTHORITIES: The information is sought pursuant to Vienna Convention on Diplomatic Relations of 1961; Vienna Convention on Consular Relations of 1963; Diplomatic Relations Act (22 U.S.C. 254a-e); and International Organizations Immunities Act (22 U.S.C. 288e (a)).
PURPOSE: The principal purpose for the collection of this information is to notify the U.S. Department of State of the appointment of foreign government employees so the Department can therefore extend various privileges and benefits granted by the above-cited authorities which are predicated upon review and acceptance of this information by the U.S. Department of State.
ROUTINE USES: The principal users of this information are offices within the U.S. Department of State, including but not limited to, the Office of Protocol, the Office of Foreign Missions, and the Office of Visa Services. In response to inquiries from law enforcement agencies, the Office of Protocol may confirm status as recognized by the U.S. Department of State as covered under STATE 36, Security Records. Information may also be provided to other government agencies having statutory or other lawful authority to maintain such information. Names of the members of diplomatic staff, office addresses, titles, and names of spouses are published quarterly in the Diplomatic List, U.S. Department of State Publication 10424. Names of Consular Officers, titles, and office addresses are published semi-annually in Foreign Consular Offices in the United States, U.S. Department of State Publication 10277.
DISCLOSURE: Providing this information is mandatory. Failure to provide the information requested on this form may prevent acceptance and the extension of benefits to principals or family members as provided in the above-cited authorities.
ANY CHANGES IN THIS INFORMATION MUST BE REPORTED IMMEDIATELY TO THE DEPARTMENT OF STATE (USE FORM DS-2006, NOTIFICATION OF CHANGE)
*Public reporting burden for this collection of information is estimated to average 20 minutes per response, including time required for searching existing data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final collection. You do not have to supply this information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy of this burden estimate and/or recommendations for reducing it, please send them to: M/OFM, 3507 International Place NW, Washington, DC 20008.
