H-1B/E-3/TN Visa Intake Form

International Scholars Operations

PART I: To be completed by the international scholar being invited to the University of Washington (UW).

  1. Biographical Information

Enter names as they appear on the passport

Full Name:Family name/surname, First name/given name Middle initial (if any)

Date of Birth: MM/DD/YYYYGender: Male Female

City of Birth:City/town of birthProvince/State of Birth:Province/state of birth

Country of Birth:Country of birthCountry of Citizenship:Country of citizenship

Permanent Address Outside the U.S. (if any):Address line 1

Address line 2

Address line 3

Address line 4

Do you have a U.S. Social Security number (SSN)?YES NO

Are you currently in the U.S.?YES NO

If YES, list your U.S. residence address: Address line 1

Address line 2

Address line 3

Address line 4

If YES, list current nonimmigrant status and date of last arrival?

Nonimmigrant statusMM/DD/YYYY

Select oneof the following ifyou have made any prior visits to the U.S.:

For each prior visit to the U.S. (except as a B-1 or B-2 or visa waiver), list your nonimmigrant status and dates of stay:

Enter nonimmigrant status and dates of stay (MM/DD/YYYY - MM/DD/YYYY)

Indicate the city and country of the U.S. consulate to be notified by U.S. Citizenship and Immigration Services (USCIS) when the petition is approved. Or, if you are Canadian, indicate the pre-flight or port of entry inspection facility.

Enter U.S. consulate or inspection facility

Have you ever been granted H-1B classification?YES NO

Have you ever been denied H-1B classification?YES NO

Are you in removal (deportation) proceedings?YES NO

Present Occupation:Enter your official occupation

Present Job Title:Enter your official title

Present Employer’s Name and Address: Employer name

Address line 1

Address line 2

Address line 3

Address line 4

Highest Degree Earned:Enter the official degree

Field of Study:Enter the official field name

Name of Granting Institution:Enter the official name

Date Received:MM/DD/YYYY

Are you a graduate of a foreign medical school?YES NO

If YES, have you passed all three steps of the U.S. Medical Licensing Exam (USMLE)?YES NO

  1. Information About Your Dependents
  • Dependents includeyour spouse and children under age 21.
  • List dependents only if they are coming to the U.S. or are currently in U.S. in H-4 status.
  • Do not list dependents who hold U.S. passports or dependents who were born in the U.S.
  • Enter names and dates exactly as they appear in passports.
  • If you have more than three dependents, list them on a separate page.

Dependent One:

Relationship: Spouse Child

Full Name:Family name/surname, First name/given name Middle initial (if any)

Date of Birth:MM/DD/YYYY

Gender: Male Female

Dependent Two:

Relationship: Spouse Child

Full Name:Family name/surname, First name/given name Middle initial (if any)

Date of Birth:MM/DD/YYYY

Gender: Male Female

Dependent Three:

Relationship: Spouse Child

Full Name:Family name/surname, First name/given name Middle initial (if any)

Date of Birth:MM/DD/YYYY

Gender: Male Female

  1. Additional Information

Use this space to enter additional information if necessary:Enter your response

PART II: To be completed by the UW unit that is inviting the international scholar.

  1. Funding Information

UW Appointment Service Period: 9-month 12-month

UW Monthly Full-Time Salary: Include only salary paid through UW payroll for the proposed dates of sponsorship. Monthly full-time salary does not include pay through PDR or clinical revenue. DO NOT round off amount; salary must equal yearly amount in employer’s letter to USCIS, including cents:$XX,XXX.XX

If compensated through clinical practice plan (UWP or CUMG), list source and per-month amount:Enter your response

  1. Appointment Information

UW Appointment Title: Select one title from the list below, then type or copy and paste the title and job class code into the text box.Enter the UW appointment title (from the list below)

Updated August 28, 2012H-1B/E-3/TN Visa Intake FormPage 1 of 4

https://ap.washington.edu/iso/sites/default/files/H-1B-Visa-Intake-Form.docx

Acting Assistant Professor, pending PhD - 0123

Acting Assistant Professor, temporary - 0125

Acting Assistant Professor/Senior Fellow Trainee - 0125/0442

Acting Assistant Professor/Senior Fellow - 0125/0442

Acting Associate Professor - 0122

Acting Instructor - 0124

Acting Instructor/Senior Fellow Trainee - 0124/0442

Acting Instructor/Senior Fellow - 0124/0445

Acting Instructor/Senior Fellow/Senior Fellow Trainee - 0124/0445/0442

Acting Professor - 0121

Assistant Professor - 0116

Assistant Professor without Tenure - 0113

Associate Professor - 0102

Associate Professor without Tenure - 0112

Chief Resident - 0329

Clinical Assistant Professor, salaried - 0167

Clinical Associate Professor, salaried - 0166

Clinical Instructor, salaried - 0168

Clinical Professor, salaried - 0165

Fellow - 0444

Lecturer - 0115

Lecturer Full Time Competitive Recruitment - 0179

Principal Lecturer - 0180

Professor - 0101

Professor without Tenure - 0111

Research Assistant Professor - 0143

Research Associate - 0148

Research Associate-Trainee - 0150

Research Associate Professor - 0142

Research Professor - 0141

Research Technologist 2

Research Technologist 3

Resident - 0328

Senior Fellow - 0445

Senior Fellow,Trainee - 0442

Senior Lecturer - 0117

Visiting Assistant Professor - 0133

Visiting Associate Professor - 0132

Visiting Lecturer - 0135

Visiting Professor - 0131

Other or Not Listed Title (must be pre-approved by ISO)

Updated August 28, 2012H-1B/E-3/TN Visa Intake FormPage 1 of 4

https://ap.washington.edu/iso/sites/default/files/H-1B-Visa-Intake-Form.docx

Proposed Dates of Sponsorship (up to three years for H-1B or TN; up to two years for E-3):

MM/DD/YYYYtoMM/DD/YYYY

UW activities to be performed by the beneficiary (check as many as applicable):

Teaching

Research

Clinical training in a residency or fellowship

Clinical-patient care (including in a teaching setting)

Other. If “Other,” please specify: Enter your response

List all activity locations, including street address and zip code, where employment will be performed, as well as the dates (MM/DD/YYYY) at each. For short assignments, also list anticipated number of weeks. Include an itinerary if one exists. If there are more than four locations, include a separate attachment.

  1. Activity address and dates (MM/DD/YYYY - MM/DD/YYYY)
  2. Activity address and dates (MM/DD/YYYY - MM/DD/YYYY)
  3. Activity address and dates (MM/DD/YYYY - MM/DD/YYYY)
  4. Activity address and dates (MM/DD/YYYY - MM/DD/YYYY)

Does the position require a license?YES NO

Will the position be 100% FTE with 100% salary distribution for the entire appointment period?YES NO

  1. Sponsoring Unit Information

UW Academic Home Department:Enter the official name

UW UnitContact Details (for further information regarding this visa request):

Contact’s Email:UW

Campus Box:35XXXX

Campus Phone:5-5555

UW Unit Budget Details(for processing fee):

Budget Name:Enter the official name

Budget Number:XX-XXXX

Budget Option/Project/Task: XX-XX-XX

Budget Contact Name:First and last name

Budget Contact’s Email: UW

Chair’s/Director’sName:First and last name

Dean’s/Chancellor’sName:First and last name

Dean’s/Chancellor’s Office Contact’s Name: First and last name

Dean’s/Chancellor’s Office Contact’s Email: UW

  1. Additional Information

Use this space to add comments or information:Enter your response

Updated August 28, 2012H-1B/E-3/TN Visa Intake FormPage 1 of 4

https://ap.washington.edu/iso/sites/default/files/H-1B-Visa-Intake-Form.docx