Exchange Visitor Information Form

/ Active Minds Changing Lives
International Student & Scholar Services / 516 High St. MS 9078-S
Bellingham, Washington 98225
Phone (360) 650-6517

EXCHANGE VISITOR INFORMATION FORM

Once this request form and other required supporting materials from the hosting department have been received, International Student & Scholar Services (ISSS) will prepare the Certificate of Eligibility for Exchange Visitor Visa (J-1) Status within 10 business days. ISSS will send the certificate (Form DS-2019) to the hosting department for forwarding on to the exchange visitor.

NAME (Name must appear exactly as it is written in the passport)

______

(Family/Last Name) (First/Given Name) (Middle Name or “None”)

Date of birth: ______/______/______

MM DD YYYY

Gender: _____ Male _____ Female

Country of birth: ______

City of birth: ______

Country of citizenship: ______

Country of legal permanent residence: ______

Residential address in home country:

______

E-mail address:______

Current occupation (job title) in home country:___ Undergraduate Student

___ Graduate Student

___ Professor

___ Researcher

___ Other (Please specify)

Name of institution, agency, organization, or employer in home country:

______

Will you be visiting other institutions on business during the time in the U.S.? ____ Yes ____ No

Institution: ______From: ___/___/_____ To: ___/___/_____ MM DD YYYY MM DD YYYY

Full address: ______

Institution: ______From: ___/___/_____ To: ___/___/_____ MM DD YYYY MM DD YYYY

Full address: ______

Are you currently in the U.S.? _____ Yes _____ No If “Yes” do you plan to travel out of the U.S. prior to coming to WWU? _____ Yes _____ No Date: ___ /___ /______(MM/DD/YYYY)

If in the U.S., what visa status do you currently hold? ______

Have you ever been in the U.S. on a J-1 or J-2 visa? _____ Yes _____ No

If “Yes” pleaseindicate beginning and ending dates:

______

If you have held J-1 status before, what category were you in? (i.e., Professor, Research Scholar, Short-term Scholar, etc.)

______

Will you be accompanied by family(spouse and/or children)?_____ Yes _____ No

If accompanied by family, please include information about all non-U.S. citizen dependents below.

NOTE: Name must appear exactly as it is written in the passport

Name: ______

(Family/Last Name) (First/Given Name) (Middle Name or “None”)

Please check one:______Spouse ______Child (under age of 21)

Date of birth: ______/______/______Gender: _____ Male _____ Female

MM DD YYYY

Country of birth: ______

City of birth: ______

Country of citizenship: ______

Country of permanent residence: ______

Name: ______

(Family/Last Name) (First/Given Name) (Middle Name or “None”)

Please check one:______Spouse ______Child (under age of 21)

Date of birth: ______/______/______Gender: _____ Male _____ Female

MM DD YYYY

Country of birth: ______

City of birth: ______

Country of citizenship: ______

Country of permanent residence: ______

Funding: If funding is being provided by a source other than WWU, please provide documentation for ALL funding sources that will be used to support the your stay.

Documentation from sources other than WWU should be provided on institutional letterhead with a translation in English. If personal funds will be used to support your stay, a personal bank statement can be provided to show proof of the availability of funds.

Funding must demonstrate a minimum of $1500 per month for the scholar, $600 per month for the spouse, and $400 per month for each additional dependent.

Please note that you may be required to show proof of finances again at the time of application for a visa at the U.S. consulate or at the U.S. port of entry.

Funding Source Funding AmountDocumentation

($U.S.) (See note above)

WWU (including grants from external sources) $U.S.______Yes

U.S. government agency $U.S.______Yes

International organization $U.S.______Yes

Government of home country $U.S.______Yes

Other organizations providing support $U.S.______Yes

(ex: home university)

Personal funds $U.S.______Yes

Exchange Visitor Checklist

Please ensure that all of the following items are completed and attached BEFORE sending this request to the sponsoring department:

______Completed Exchange Visitor Information form

______Copy of current curriculum vitae

______Copy of passport ID page

______Copy of all dependent passport ID pages (if dependents are coming with exchange visitor)

______Copy of supporting documentation showing proof of finances (if finances are coming from an organization outside of WWU; i.e., home university or government sponsor, or exchange visitor’s personal funds)

Exchange VisitorAttestation

I certify that the information contained in this application is correct and accurate to the best of my knowledge and:

I understand the financial requirements for J-1 visa sponsorship.
The amount of financial funding is readily available to me. I will notify WWU International Student & Scholar Services (ISSS) of any changes in funding.
I understand that all Exchange Visitors and their accompanying dependents must be covered under a health insurance policy that meets the minimum standard established by the US Department of State. I further understand that failure to comply with this health insurance requirement will result in cancellation of the my J-1 status.
I will notify ISSS if I cannot arrive within 30 days of the start date provided on the DS-2019 document.

Signature: ______Date: ______

Please forward request form and accompanying documentation to your WWU hosting department.