Office of International Services (OIS)
The University of Texas Health Science Center at San Antonio
San Antonio, TX 78229
Tel: (210)567-6241 Fax: (210)567-6240
J-1 EXTENSION APPLICATION FORM
Request For Extension Of Stay
This form is to be completed by the Exchange Visitor’s UTHSCSA Departmental Sponsor/Supervisor. Please type.
1. NAME OF EXCHANGE VISITOR:
Last First Middle SEVIS ID
2. PURPOSE OF EXTENSION:
3. BRIEF NON-TECHNICAL DESCRIPTION OF ACTIVITY VISITOR WILL ENGAGE IN DURING REQUESTED
EXTENSION OF STAY:
4. POSITION TITLE:
*Note: Federal Regulations limit changes in program and length of stay. Please contact the Office of International Services if there is any planned change in the visitor’s original objective.
5. DATES OF EXTENSION OF STAY: From (MM/DD/YYYY) to
Note: Extensions are done for no more than two years at a time. Under certain circumstances, an extension
may not be possible.
6. TOTAL AMOUNT OF FINANCIAL SUPPORT FOR EXTENDED STAY (U.S. DOLLARS) $
Note: The minimum amount of funding must total $26,000/year for the J-1, plus $4,675/year per J-2 dependent. Financial documents must be attached (Letter of offer or bank letter).
(A) Total Amount of UTHSCSA Support: $ per year per month; Project ID:
(B) SUPPORTS OTHER THAN UTHSCSA. List all financial sources (names) and dollar amounts per year or month:
7. Dependent Information
List the Names, Relationships, Citizenships, Birthdates, and Birthplaces of ALL Dependent Family Members (Spouse and Unmarried Children Under the Age of 21 Only) who will accompany the visitor. NOTE: Correct spelling is VERY important, names should appear as in passport. PLEASE PROVIDE A COPY OF PASSPORT NAME PAGE FOR EACH DEPENDENT.Family Name / Given Name / Middle Name
(Required) / Relationship to applicant / Country of Citizenship / Country of Legal Permanent Residence / City and Country of Birth / Birth Date (mm/dd/yy)
8. Supervisor’s Printed Name: Title:
Supervisor’s Signature:______Department: Tel:
Departmental Contact’s Name: Tel:
Date: E-Mail Address: Fax Number:
APPENDIX
Please submit the following required documents TO OIS with the Form
You must communicate your intent to extend to OIS at least 45 days before the expiration date of your current DS-2019.
1. J Extension Application Form
2. Copy of Scholar’s Passport Information (Name) Page
3. Copy of the visitor’s resume/CV
4. Copy of the visitor’s U.S. Visas
5. Copy of the visitor’s I-94 (both sides)
6. Copy of visitor’s previous DS-2019
7. Copy of dependent’s U.S. Visas, I-94 (both sides), and DS-2019 (if applicable).
8. Copy of Diploma of Highest degree the applicant received
9. Letter from EEO approving the position (only for faculty position)
10. Letter from UTHSCSA department signed by Chair stating the reasons of the program extension including the new beginning date, ending date, payment (if receiving funding from UTHSCSA), and a description and objective of program, the role of the scholar in the research project, etc. Note: If no funding is offered by UTHSCSA, the applicant must show proof of financial stability, which can be in the form of bank letter and Sponsor’s Letter of support printed on the sponsor’s letterhead proving that the applicant has the enough funds to cover the living expenses.
11. Proof of insurance coverage
a. If paid by UTHSCSA, proof of coverage is needed for the entire employment. This can be a copy of the insurance policy or the insurance card.
b. If visitor is not paid by UTHSCSA, insurance coverage is required for the duration of stay.
12. J Program Conditions Statement
13. Statement of No patient Contact or Incidental patient contact
NOTE:
A. We will notify the Department Contact Person when all documents are ready. It is the department’s responsibility to pick up the DS-2019 and other documents from Office of International Services.
B. All documents must have notarized translation of English.
C. Should you have any questions regarding the application procedures and
Documents, please contact Office of International Services at 567-6241 or fax
567-6240.