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  National High Magnetic Field Laboratory, NHMFL

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Visitor Information Form

Please fill out the following information for all participants and make sure all fields are completed before submitting form.

If you do not wish to send your personal information over the internet, please print the form on this page and fax it to Julie Gallegos at
(505) 665-4311.

Fields marked with an asterisk (*) are required fields

A) PERSONAL INFORMATION

Title:*
First Name:*
Last Name:*
Middle Name:
Date of Birth:* (mm/dd/yyyy)
City of Birth:*
State/Region of Birth:
Country of Birth:*
Country of Citizenship:*
By checking this box I acknowledge that if I fail to bring the following approved identification, original birth certificate, passport, or military id. I will not have access to the Laboratory.* No Yes
Currently Overseas?: Yes No
Social Security Number:

Submission of demographic data is voluntary. NSF requests this information to assist them in (1) gauging whether programs and opportunities are fairly reaching and benefiting everyone regardless of demographic category, (2) ensuring that under-represented groups have the same knowledge of and access to programs, meetings, research and educational opportunities, and (3) assessing involvement of international investigators or students in NSF-supported work. Thank you for your cooperation.

Gender: female male

Minority Qualifications: 1) You must be a US citizen AND 2) Ethnicity - Hispanic or Latino, 3) Race - American Indian or Native Alaskan, Black or African American, Native Hawaiian or Pacific Islander.

Minority: Yes No

School/Business Affiliation Information

Name of Employer/School:*
Number and Street:*
City:*
State:*
Zip Code:*
Country:*
Employer/School's Phone Number (with area code):*
Employer/School's Fax Number (with area code):
Employer/School's Email:*
Position/Title:*
Discipline/Area of Expertise:*

Home Address Information

Number and Street:*
City:*
State:
Zip Code:*
Country:*
Home Phone Number (with area code):*
Home Email:
Non-US Citizens proceed to sections non-US citizen
US Citizens proceed to section US citizen

B) ADDITIONAL INFORMATION

Name of Last Employer/School in Home Country:
Number and Street Address of Last Employer/School in Home Country:
City of Last Employer/School in Home Country:
Country of Last Employer/School in Home Country:
Phone Number of Last Employer/School in Home Country (with area code):
Title with Last Employer/School in Home Country (student, Postdoc, Prof.):
Discipline/Area of Expertise:
Please fill out the Passport and Visa information or the Permanent Residence information.

Passport and Visa Information

Passport Number:
Passport Expiration Date: (mm/dd/yyyy)
Visa Type:
Visa Issue Date: (mm/dd/yyyy)
Visa Expiration Date: (mm/dd/yyyy)

Permanent Residence Information

Permanent Residence Number:
Date of Issue: (mm/dd/yyyy)
Expiration Date: (mm/dd/yyyy)
Passport and Visa OR Permanent Residence Card must be presented at the badge office upon arrival at Los Alamos National Laboratory (LANL).

C) NHMFL VISIT INFORMATION

Begin Date: (mm/dd/yyyy)
End Date: (mm/dd/yyyy)
Purpose of Visit (Title of Experiment):*
Do you plan to bring a laptop computer to LANL for use during your magnet time? Yes No
Hotel Reservations Needed? Yes No
Date of Arrival in Los Alamos:* (mm/dd/yyyy)
Arrival Time in Los Alamos:*

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