DISAM Form GSI-001 Guest Speaker Request

GUEST SPEAKER REQUEST
ALL FIELDS in BLUE ARE REQUIRED and ALL INFORMATION IS PROTECTED BY THE PRIVACY ACT OF 1974 (see remarks)

Speaker Information
Full SSN (see below)

First Name

Middle Initial

Last Name

Grade / Rank

Position Title

Zip Code

Mailing Address

City

State / Country

Official Email Address

Official Phone # (Commercial or DSN)

Official FAX # (Commercial or DSN)

Course Information
Please list all blocks separately that Guest Speaker will be supporting
Course #

Block #

Date

Course Title

Time

Day

Course #

Block #

Date

Course Title

Time

Day

Course #

Block #

Date

Course Title

Time

Day

TDY Information
Yes

No

Yes

No

Yes

No

Yes

No

DISAM Funded

VOQ Required

Airline Reservations Required

Rental Car Required

By signing below I verify that I or my Division Supervisor has reviewed the requirements to accomplish the mission and determined that an alternate means of communication such as video and teleconferencing
are insufficient to accomplish the objectives of this travel.

Requester Information
Signature

Name

DISAM Host Name

Date

OMB CONTROL NUMBER: 0704-0548
OMB EXPIRATION DATE: XX/XX/XXXX

PRIVACY ACT STATEMENT: Authority: 10 U.S.C. 134, Under Secretary of Defense for Policy; DoD Directive 5105.65, Defense Security Cooperation Agency (DSCA); DoD Directive 5105.38-M, Security
Assistance Management Manual, Chapter 10; DoD Directive 5132.03, DoD Policy and Responsibilities Relating to Security Cooperation; Army Regulation 12-15, SECNAVINST 4950.4B, AFI 16-105,
Joint Security Cooperation Education and Training ; Public Law 97-195, Foreign Assistance and Arms Export Act of 1961, as amended; E. O. 9397, SSN, as amended. Purpose: The primary use of this
information is purposes of efficient administration of U.S. and international students, and the effective management of DISAM personnel and guest lecturers. Routine Use: Contents shall not be disclosed,
discussed or shared with individuals unless they have a direct need-to-know in the performance of their official duties. The information is collected in connection with OSD Privacy Act System Notice
DSCA-05, Defense Institute of Security Assistance Management Information System Mission (DISM). Disclosure: Providing the personal information is voluntary. However, failure to provide the requested
information may result in ineligibility of certain program opportunities and prevent access to US installation.
AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching 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 the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Directives Division, whs.mc-alex.esd.mbx.dd-dod-informationcollections@mail.mil. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does
not display a currently valid OMB control number. SSN is required for honorarium IRS Form 1099 for tax purposes.

Date Received

Date Recorded

DISAM Form GSI-001