Checklist for Certificate of Eligibility for J Status Form

							  Checklist for Certificate of Eligibility for J-1 Status (Form DS-2019)

The purpose of the J-1 program is to provide foreign nationals with the
opportunity to participate in educational and cultural programs in the US. It is
designed to enhance their experience while contributing to their development.

The exchange program encourages US professionals to participate in similar
programs abroad. This program is intended for professors, research scholars,
and or professionals seeking to enlighten their development in the U.S. The
maximum period of entry for short- term scholars is six (6) months.
Extensions beyond this period are not authorized. Unlike the other J-1
categories, there is no minimum period of stay in the U.S.

The following documents must be included with this application:

   Copy of Letter of good academic standing from Dean of current medical
   school.

   Copy of updated Curriculum Vitae

   Proof of health insurance valid for the duration of visit and valid in the U.S.
   The Exchange Visitor regulations specify a minimum level of coverage.
         o Medical benefits of at least $50,000 per accident or illness
         o Repatriation of remains in the amount of $7500
         o Expenses associated with medical evacuation of the Exchange Visitor to his or
             her home country in the amount of $10,000
         o A deductible not to exceed $500 per accident or illness.
   Copy of biographic page in unexpired passport
   Proof of financial funding. For all exchange visitors with funding sources
   other than Mount Sinai, please attach documentation such as a letter from
   sponsors, universities or government agencies, bank statement showing
   funds available for the duration of your stay. If the funding is coming from
   two different sources please distinguish.

             The document must be in English and contain the following:
                Name of applicant and relation to the funding sponsor
                The period of time the funding will be granted
                The amount of financial support in U.S. dollars. (Minimum of $1600/month)
                The document must be notarized, on official letterhead of the supporting
                organization and must be signed by an authorized official of the
                organization.

   Copies of all prior issued visas including DS-2019 forms, etc.

   $200 Disbursement Fee. Payment should be made directly to the Main
   Cashier upon arrival. Payment is accepted in the form of check or money
   order payable to Mount Sinai Medical Center. No credit card payments are
   accepted. Deposit Invoice attached.
Checklist Certificate of Eligibility for J-1 Status (Form DS-2019) cont’d

   If immediate family members (such a spouse and children under 21 years of
   age) will accompany the exchange visitor, please include a copy of marriage
   certificate and birth certificate of children to establish proof of relationship.
   Completed applications and supporting documents may be submitted via air

Courier Service:                                    Postal Service:
Mount Sinai Medical Center                          Mount Sinai Medical Center
International Personnel                             International Personnel
Attn: Yovanna Torres                                Attn: Yovanna Torres
320 E 94th Street, 5th Floor                        One Gustave L. Levy Place
New York, NY 10128                                  Box 1514
℡ 212-731-7744                                      New York, NY 10029

Please submit all required documentation and allow at least three (3) weeks for
processing. Incomplete applications will cause delay. The office of International
Personnel will communicate any request for additional documentation directly
to the exchange visitor via email.

While request try to prioritize cases on first come first serve basis, priority will
be given to the start date requested.

It is important that you read and understand the following.

Once you obtain the SEVIS generated form DS-2019 you will require
scheduling an appointment with the US embassy to apply for the J-1 visa. You
will require taking with you your passport, form DS-2019 and the I-901 SEVIS
fee receipt. As an initial participant in an exchange visitor program, you will be
required to pay a mandatory remittance fee (SEVIS I-901 fee) of $100
authorized by Public Law 104-208, subtitle D. section 641. This fee is required
for the maintenance of the Student Exchange Visitor Information System
(SEVIS). If you do not pay the fee and appear for your interview at the embassy
without proof of payment, your visa will not be issued. You can make this
payment online with a credit/debit card at www.fmjfee.com

Visa issuance processing times at consulates vary and you should plan your
trip accordingly. It is recommended that you secure your visa before making
travel arrangements.
   Complete and submit this portion only with the required documentation to International Personnel.

   Application for Certificate of Eligibility for J-1 sponsorship

Please specify the purpose of the Exchange Visitor’s status:

Requested Period of Elective: From _____/______/_____ To _____/______/______
                                                 Mo.      Day        Year       Mo.       Day          Year
______________________________________________________________________________

Part I: Exchange Visitor’s Biographic Information (PLEASE PRINT)

Name: _______________________                  _____________________              ___________________
                Family Name                      First/Given name                       Middle Name

Male _______ Female ________         Date of Birth: ________/_______/________
                                                    Month     Day     Year
Place of Birth: ______________________________ ______________________________
                  City, State or Province             Country

Country of Citizenship: ____________________________________________________
Country of Legal Permanent Residence: ____________________________________


Permanent Foreign Address: (required)                     Current U.S. Address: (Upon Arrival)
________________________________                          ________________________________
________________________________                          ________________________________
________________________________                          ________________________________



Home Telephone: ______________________ Work Telephone:___________________

Mobile: ________________________                 Email:____________________________________

Exchange visitor’s most recent position in home country: _________________
If student, please specify by checking the following:
Undergraduate ________          Graduate _______          Medical _______

Has you ever applied and been approved for a U.S. visa? If so, when and on which type of visa
status?
______________________________________________________________________________
______________________________________________________________________________
Part II: Financial Support Information

1. Source and Breakdown of Support: (If the institution will be paying the
   employee directly, please confirm that the funds will be deriving directly from
   Mount Sinai. If the funding is coming from two different sources please
   distinguish. The minimum funding requirements for a J-1 exchange
   visitor is $1,600 per month.

Funding listed below is:   Per month         For the duration of the stay


Source of Funds                  Amount of Funds*              Name of Funding Source
 Mt. Sinai School of
 Medicine
  U.S. Government Agency
  International
  Organizations
  Exchange Visitor’s Gov’t**
  Other Organization’s
  providing support
  Personal Funds
* Indicate Total amounts of funds in USD
** Check only if the individual is receiving funds DIRECTLY from a U.S. Government Agency

If non-salaried, will the institution provide medical coverage that meets the J-1
exchange visitor regulations minimum requirement?
Yes ___ No ____.

If No, exchange visitor must submit a health insurance policy that medical
coverage has been secured for self and family during the dates of participation.


********** Health insurance is required before DS-2019 is issued. **********
Part III: Exchange Visitor’s Work Site Duties

Is this Exchange Visitor a graduate of a foreign medical school?
Yes________ No __________

If “Yes,” indicate the level of clinical care in which this individual will perform:

   _____ A. The program in which the physician will participate involves
   clinical training or clinical research.

   If “A” is checked please STOP.
The individual must be sponsored by the Educational Commission for Foreign
Medical Graduates (ECFMG) or apply for an H-1B visa. Note: To qualify for the
H-1B category you must have passed all three steps of the USMLE examination
and have the appropriate licenses. For information on how to contact ECFMG,
or how to apply for an H-1B visa, please contact the office of International
Personnel at (212) 731-7744.

   ____ B. The program in which the physician will participate involves no
   element of patient care services.

   ____ C. The program in which the physician will participate involves
   incidental patient contact. All such patient contact will be under the
   supervision of a physician who is a U.S. citizen or permanent resident who
   is licensed to practice medicine in the State of New York. The foreign
   physician will NOT be involved in or responsible for the diagnosis and/or
   treatment of patients. The foreign physician will NOT be involved in any
   patient care activity, which would normally require a medical license. No
   experience gained in this program will be creditable toward any clinical
   requirements for medical board certification. (Please note that graduates of
   medical schools cannot be registered as or treated as medical students for
   patient care services.)

   ***PLEASE ATTACH DEAN’S STATEMENT IF LETTER “C” SELECTED***
Part V: Information about Exchange Visitor’s Dependent Family
Member(s)

A. Spouse Information:

Name of spouse: ___________________ _____________________ _________________
                   Family Name        First/Given name      Middle Name

Male _______ Female ________              Date of Birth: ________/_______/________
                                                            Month       Day       Year
Place of Birth: _______________________________             ___________________________
                 City, State or Province                     Country

Country of Citizenship: _____________________________
Country of Permanent Residence_____________________

      Spouse will travel with exchange visitor.
      Spouse will arrive later. Expected arrival date, if known _______________.
      Spouse is already in the U.S., and will need a transfer, extension, or
      change of status. Please specify: _______________________.

B. Children Information:

Name of Child: ____________________         ______________________ ________________
                   Family Name                First/Given name        Middle Name

Male _______ Female ________           Date of Birth: ________/_______/________
                                                       Month    Day      Year
Place of Birth: __________________________          _____________________________
                 City, State or Province             Country

Country of Citizenship: _______________________________
Country of Permanent Residence______________________

      Child will travel with exchange visitor.
      Child will arrive later. Expected arrival date, if known__________________.
      Child is already in the U.S., and will need a transfer, extension, or
      change of status. Please specify: ___________________________.



              *** If there are more children please add an additional page. ***

    Note: All J visa applicants must have an intention to return to their home country.
Part VI – Faculty Information and authorization of sponsorship.

Without the following authorization from the faculty sponsor, the DS-
2019 certificate of eligibility cannot be issued to the exchange visitor.

Full Name of Faculty Sponsor: _______________________________________________
Full Name of Exchange Visitor: _______________________________________________

THE UNDERSIGNED CONFIRMS that he or she is authorized to offer this
position, that he or she will take responsibility for the supervision of the visitor,
and that the information contained in this request is accurate to the best of his
or her knowledge.

Signature of Faculty Sponsor: _____________________ Date: ____________________

Department: __________________________

Location: ____________________________________________________________________

Contact Person: __________________________ Telephone: _______________________

Email Address: ____________________________________ Fax: ____________________




Please Note: While request try to prioritize cases on first come first serve
         basis, priority will be given to the start date requested.
                     DEPOSIT INVOICE
To:        Main Cashier, Mount Sinai Medical Center

From:      International Personnel

Re:        Deposit into account 0103-3029-3000



Please deposit the funds listed below at the main cashier located at
Guggenheim Pavilion, 1st floor, East Tower. The receipt should be brought
back to International Personnel for case processing.

ALL checks and money orders are to be made payable only to: The Mount
Sinai Medical Center

Method of Payment        ‫ ڤ‬Cash      ‫ ڤ‬Money Order              ‫ ڤ‬Check #_____



‫ 002$ ڤ‬J1 processing Fee


Petitioner’s LAST Name_______________________________________________

Petitioner’s FIRST Name______________________________________________

Date _____________




OFFICE USE ONLY

Case # _______________
Code: 1
      2
      3
      4                               _____________________________________
                                            Signature/Date