J1 Visa Forms

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					                              DS-2019 (J-1 VISA) REQUEST FORM
Please print legibly:
Purpose of Request:
          New J-1
          J-1 Extension
          J-1 Transfer (from another institution)

Category of Visitor (check one only):
          Professor (teach, lecture, 5 year limit)
          Research Scholar (engage in research, 5 year limit)
          Short-term Scholar (up to 6 months to lecture, observe, consult, and to participate in
          seminars, workshops, conferences, or similar types of education and professional

   1. Visitor’s name:
                    (Family Name)                        (First Name)       (Middle)
   2.     Male             Female

   3. Date of birth: _____________ Birthplace: ____________________________________
                        (MM/DD/YYYY)                  (City)              (Country)
   4. Citizen of: __________________ Legal permanent resident of: ___________________
                  (Country)                                              (Country)

   5. Visitor’s current mailing address (to mail DS-2019 form): ________________________
   6. Visitor’s permanent address: _______________________________________________
   7. Position/Occupation in home country: ________________________________________

   8. Visitor’s employer (name, location): __________________________________________

   9. Supervisor at MIIS: _______________________________________________________
      Telephone number: ____________________ E-mail: ___________________________

   10. Period of requested stay (contract dates): ____________ to ______________
                                                     (MM/DD/YYYY)        (MM/DD/YYYY)

   11. Program Objectives: Carefully state the Program Objectives that the exchange visitor
       will be pursuing while at MIIS:
12. Financial verification: Please check and complete the following as appropriate and
    attach documentation of financial support from any source other than MIIS.

   Funding for this Exchange Visitor will be provided by:
      MIIS                                                     $ ______________________
   (The person signing this form is responsible for assuring payment. Must match contract.)
           US Government Agency (Direct award to the visitor)     $ ______________________
           Source of funding: ___________________________
                                 (Name Of Agency)
           Exchange Visitor’s government                          $ ______________________

           Bi-national commission of the Visitor’s country        $ ______________________

           Other organizations providing support                  $ ______________________
           Source of funding: ________________________
           Personal funds (attach bank statement)                 $ ______________________

NOTE: Personal funds should be verified by having the Exchange Visitor provide a bank
    certification or letter indicating availability of funds.

13. 12-month Bar of Scholars: According to regulations, any individual who held J-1 status
    (other than short-term scholar category) for a period longer than 6 months at anytime
    within the past 12 months is not eligible to return as a J-1 Research Scholar or Professor
    until one year has elapsed from last exit in J-1 status.

Has the applicant been an exchange visitor in the US any time within the past twelve (12)
months?       No        Yes. If yes, please give dates as indicated on previous DS-2019 forms
(attach copies if available) ____________________________________________________

   Dates              Category                 Purpose of Visit

14. Repeat Participation: Exchange participants who have entered the United States under
    the Exchange Visitor Program as a professor or research scholar, or who have acquired
    such status while in the U.S., and who have completed his or her program are not eligible
    for participation as a professor or research scholar for a period of two (2) years.

Has the applicant been an exchange visitor in the US any time within the past twelve (12)
months?       No        Yes. If yes, please give dates as indicated on previous DS-2019 forms
(attach copies if available) ____________________________________________________

   Dates              Category                 Purpose of Visit

   Dates              Category                 Purpose of Visit
   15. Transfer: Is the Exchange Visitor transferring from another Exchange Visitor program
       in the US?   No    Yes. If yes, please attach DS-2019 form from current Exchange
       Dates              Category                Purpose of Visit

   16. USIA regulations state that “the Exchange Visitor must possess sufficient proficiency in
       the English language to participate in his or her program.” The requestor has verified
       English proficiency in the following way:
               Telephone Conversation                  TOEFL Score              Personal Interview

   17. Required health insurance: Health and accident insurance is mandatory for all
       Exchange Visitors and their dependents. The Institute’s group medical plan meets
       regulatory requirements, if the Visitor is eligible for benefits. If the Visitor is not
       eligible for benefits, the insurance premiums will be paid by the individual and not
       by MIIS. If the Visitor is accompanied by dependents, please note that the Visitor may
       incur significant costs in maintaining the required insurance for the duration of the stay.
       If the Visitor prefers to provide his or her own insurance, he or she must submit
       verification from the insurance carrier that the insurance meets regulatory requirements
       and that the policy is effective for the entire length of stay.

   18. Dependents: (please check one)
               Exchange Visitor will not bring dependents
               Immediate family will travel with Visitor
               Family will come at a later date

Please provide the family information below if dependents will travel with the Visitor:
Name (as it appears on         Relationship Date of Birth City, Country             Country of
passport)                                                       of Birth            Citizenship

Please note that the Institute is responsible for providing and maintaining records of cross-
cultural activity “designed to promote exposure and interchange between exchange visitors and
Americans so as to increase their understanding of each other’s society, culture, and institutions.”

At the end of this exchange visitor’s participation in this program, you will need to send a
report to the Office of International Services summarizing the cross-cultural activities you
conducted for inclusion in the required annual report to United States Information Agency.
As the department sponsor of this Exchange Visitor, I attest that the information included in the
application is correct to the best of my knowledge.

Form prepared by: ___________________________________________ Date: ____________
Department Sponsor Signature: _________________________________ Date: ____________
Dean of the Graduate School Signature: __________________________ Date: ____________
Department Budget Code: ______________________

   Please return this completed form to the Office of International Services and provide a
                                         copy to Human Resources.

Responsible Officer/Manager/OIS _______________________________Date: ______________

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