Office of International Affairs

Phone: (337) 482-6819 // Fax: (337) 262-1346

E-mail: // Web:

REQUEST FOR A DS-2019 FORM

CERTIFICATE OF ELIGIBILITY FOR EXCHANGE VISITOR STATUS (J-1)

The purpose of this form is to bring an individual (and ______dependents) to the University from:

______/ A foreign country / ______/ Another U.S. School or employer
1. / Name: ______/ ______/ ______
(last or family name) / (first name) / (middle name)
2. / Gender: ______/ ______/ 3.Date of Birth: ______//______//______
Male / Female / Month / Day / Year
  1. City and country of birth: ______
  1. Country of citizenship: ______
  1. Country of legal permanent residence: ______
  1. Present or former position in country of permanent residence: ______

______

8. / Proposed dates of stay: / From: _____//_____//_____ / To: _____//_____//_____
(Mo.) (Day) (Yr.) / (Mo.) (Day) (Yr.)
  1. Host department and phone number: ______
  1. Title of proposed position: ______
  1. Brief description of responsibilities: ______

______

  1. Source and amount of funding:

______a. University of Louisiana at Lafayette$ ______

______b. Other (please specify)$ ______

13.If applicable, please list all locations and dates of previous times in J-1 exchange visitor status:

______

14.Will the exchange visitor be accompanied by spouse or children? ______Yes______No

If yes, give names, dates of birth, and places of birth on attached page.

Page 1

Date of Birth: ______//______//______

Month

Day

Year

Office of International Affairs

Phone: (337) 482-6819 // Fax: (337) 262-1346

E-mail: // Web:

DEPENDENT INFORMATION

1. Name: ______

(Family Name)(First Name)(Middle Name)

2. ______Male ______Female

3. Place of Birth:

______City: ______Country: ______

4. / Citizen of: ______/ Legal Permanent Resident of: ______
5. / Relationship to Visitor: ______
DEPENDENT INFORMATION
1. / Name: ______
(Family Name) / (First Name) / (Middle Name)
2. / ______Male ______Female / Date of Birth: ______//______//______
Month / Day / Year
3. / Place of Birth: City: ______Country: ______
4. / Citizen of: ______/ Legal Permanent Resident of: ______
5. / Relationship to Visitor: ______
DEPENDENT INFORMATION
1. / Name: ______
(Family Name) / (First Name) / (Middle Name)
2. / ______Male ______Female / Date of Birth: ______//______//______
Month / Day / Year
3. / Place of Birth: City: ______Country: ______
4. / Citizen of: ______/ Legal Permanent Resident of: ______
5. / Relationship to Visitor: ______
DEPENDENT INFORMATION
1. / Name: ______
(Family Name) / (First Name) / (Middle Name)
2. / ______Male ______Female / Date of Birth: ______//______//______
Month / Day / Year
3. / Place of Birth: City: ______Country: ______
4. / Citizen of: ______/ Legal Permanent Resident of: ______

5. Relationship to Visitor: ______

Page 2

Office of International Affairs

Phone: (337) 482-6819 // Fax: (337) 262-1346

E-mail: // Web:

Exchange Visitor Mailing Address

Address: ______

______

E-mail:

______

Telephone (work): ______Telephone (home): ______

If the individual is currently in the U.S., please complete the item below and comply with the request which follows. If the individual is not in the U.S., please skip this section.

Current immigration status (e.g., J-1, F-1, H-1B):

______

Please forward (or ask the prospective exchange visitor to forward) the following documents to the OIA:

  1. Copies of all immigration documents [DS-2019(s), SEVIS I-20(s) or I-797(s)]
  2. A copy of the current I-94 Immigration form
  3. A copy of the passport

Mail Request

______Send the DS-2019 to the prospective scholar via

Information on UL Lafayette faculty or staff requesting J-1 processing:

Name and Title: ______Date: ______

Department: ______

Phone: ______E-mail: ______

Instructions:
When completed, please forward this form to the Director of OIA. The following additional documents should be sent to the OIA with this form:
  1. A copy of the standard UL Lafayette employment offer letter (or, if no employment is involved, the UL Lafayette letter of invitation).
  2. A copy of the document(s) verifying the source and amount of any funding which is in lieu of or in addition to UL Lafayette funding.
  3. A copy of the prospective scholar’s resume or vita, if available.
  4. A copy of the prospective scholar’s/student’s passport.

Page 3