Pre-Registration Application for International Students (non-US Citizens)
Eligibility
1. Is the student visiting UCLA to participate in research or an activity under the tutelage of a UCLA faculty member?Yes No
2. Current Status in Home Country: Graduate Student Undergraduate Student Non-student
Expected graduation date (month/year): /
3. Is the student currently in the U.S? Yes No
If Yes – what is the student’s current Visa Status:
4. What will be the primary funding source for this student’s visit? Please note: In order to be eligible for J-1 visa, at least 51% of the funding must come from non-personal sources such as U.S. or home government, academic institution, scholarship funds, etc.)
Registrant Information
Full Name:Date of birth e.g. 22 April 1996: / Cell Phone #:
22 / Email:
Permanent address i.e. non-US address:
City: / State: / Zip Code:
365
65 / Country:
Home Undergraduate Institution:
Name of program/agency providing any payment (either via stipend or salary) to you:
Name of your program/agency contact:
Phone number of your program/agency contact: / Email of your program/agency contact:
Purpose of Visit
Please give a summary of activities planned at UCLA. Please note: this section should be filled out by the faculty mentor and should detail the planned research project. Attach additional documents if necessary.Will the student be auditing courses as part of this program? Yes No
Will this program involve patient contact or working in a clinical setting? Yes No
Scheduled start date of engagement: / Scheduled end date of engagement:
Applicant’s Certification
I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct. I understand that I am a visitor to UCLA and agree to respect and abide by all rules of the University.Signature of applicant: / Date:
Faculty Mentor and Department Contact Information
Faculty Mentor: / Faculty Mentor Email:Faculty Mentor Home Department Name: / Faculty Mentor Phone:
Department Contact:
Department Contact Email: / Contact Phone:
I attest that this visitor will receive all required and appropriate training. I understand that his/her safety is my responsibility.
Signature of Faculty Mentor: /
Date:
Undergraduate Research Center Use Only revised 120117
BruinCard Eligible? Yes No / Process Date:
Approved by Undergraduate Research Center for processing by UCLA Dashew Center for International Students & Scholars
Yes No
Signature of Center Director ______
Comments:
2017-12-01
Fax completed form to the Undergraduate Research Center – Sciences at (310) 267-2219 or send as .pdf file (preferred) to the Center Director Dr. Tama Hasson at . Once approved, your file will be forwarded to the Dashew Center for International Students & Scholars for initiation of J-1 Non-Degree Student Visa Processing (DS-2019).