Open Forum: Registration Form

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THE SECRETARY'S OPEN FORUM
U.S. DEPARTMENT OF STATE

Mr. Alan Lang, Chairperson
S/OF, Room 3835
U.S. Department of State, Washington, DC 20520
(202) 647-0532 Fax: (202) 647-4040

Open Forum Registration Form
(Please Print)

NOTE: Open Forum Guests must use the 23rd Street Entrance of the U.S. State Department (between C and D Streets, NW) for security clearance. If you do not have an identification badge issued by the U.S. Department of State or the U.S. Agency for International Development, please provide the following information:

Name:	______________________________________________________
Date of Birth:	______________________________________________________
Social Security Number:	______________________________________________________
Or *Passport Number:	______________________________________________________ * Non-U.S. citizens must provide a passport number in lieu of a Social Security Number.
Citizenship:	______________________________________________________
Telephone Number:	______________________________________________________
Fax Number:	______________________________________________________
E-Mail:	______________________________________________________
Organization:	______________________________________________________

Please specify the Open Forum event(s) for which you wish to register:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

The Department of State's Bureau of Diplomatic Security requires that all visitors provide this information. The use of this form for other purposes is strictly prohibited.

Please fax this registration form to: (202) 647-4040
ATTN: Ms. Terri Galloway, telephone: (202) 647-0444

Visit the Open Forum web site at:
http://www.state.gov/www/dept/openforum/