Office of International Services (OIS)

The University of TexasHealthScienceCenter at San Antonio

San Antonio, TX, 78229

Tel: (210)567-6241 Fax: (210)567-6240

F Certificate of Eligibility (SEVIS I-20) Application Form

This form is a fillable form (Electronic Version) and must be filled out on your computer

Section I. STUDENT INFORMATION

1 / Name: Last First Middle
Correct spelling is EXTREMELY important; names should appear as in passport.
2 / Male Female
3 / Birth Date: (mm/dd/yyyy): / BirthCity: State: Country:
4 / Degree Held: BS MA MD PhD Other -
UTHSCSA Degree Sought: BS MA MD PhD Other -
5 / Country of Permanent Legal Residence:
6 / Country of Citizenship:
7 / Last Position/Occupation in Home Country:
8 / A) Foreign address (P.O. Box Not Acceptable):
Tel: Fax: Email:
B) U.S. Address (P.O. Box Not Acceptable):
Tel: Fax: E-mail:
9 / Will student receive a stipend from UTHSCSA? YES NO
10 / Stipend amount:
11 / If a student is not receiving a stipend from UTHSCSA, how will he/she support him/her self?
Personal Funds Government Funds Parents Sponsor/Friend Other
Proof of Funding must be provided. NOTE: The minimum amount of funding must total the cost of tuition for oneyear and the cost of living expenses for an F-1 student. (Please note that this funding amount may change each year – tuition + $20,597.00).
12 / 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:The minimum amount of funding is $4,675 per dependent.Correct spelling is EXTREMLY 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/yyyy)
,
,
,

Section II. DEPARTMENT INFORMATION

13 / Sponsoring Department:
14 / Name and Title of Department Contact:
Phone Number: Fax Number: Email:
15 / Projected program start Date and end date: from (mm/dd/yyyy) to (mm/dd/yyyy)
16 / Degree Sought: (e.g. M.S., PhD) Major:
17 / Brief Description of activity student will be engaged in under this program (REQUIRED):

SECTION III. OTHER RELATIVE DATA

COMPLETE ONLY IF STUDENT IS PRESENTLY IN U.S.A.

18 / If applying for change of your status, your Current Visa Status:
19 / Transfer in if applicable: Yes No
If Yes, name of the student’s current institution:
International Student Advisor’s name and Title:
Tel: Fax: Email:
20 / US Telephone Numbers Including Area Code: H: - W: -
21 / SEVIS Number:
I-94 Number:
I-20 Valid from (MMDDYYYY) to
Passport Issuance Country:
Passport Expiration Date:
22 / If student is on OPT(Must attach copy of EAD card)
Starting Date:
Ending Date:
EAD Number:
If employed
Employer/Company Name:
Address:
Contact Person:
Phone Number:
Fax Number:
23 /

If student is on CPT

Starting date:
Ending Date:
Employer/Company Name:
Address:
Contact Person:
Tel:
Fax:

APPENDIX

Please submit the following required documents to OIS for your F-1 request:

1. F Certificate of Eligibility Application Form

2. Copy of student’s Passport Information Page

3. The student’s application to the program

4. Program Acceptance Letter

5. TOFLE Score (required for Undergraduate and Graduate students)

6. GRE Score (Graduate students only)

7. ORIGINALStipend letter from Department, signed by the chair, if it is not specified in

acceptance letter

If no stipend is offered by UTHSCSA, the applicant must show proof of financial

stability demonstrating enough funding to meet the minimum cost of attendance

requirements released by UTHSCSA Office of Financial Aid.

This can be fulfilled by:

  • Official Award Letter from another source (Scholarship, etc…)
  • Official Bank Statement printed on the bank’s letterhead must include the

account holder’s name, the current balance, the length of time the account

has existed, and a statement that there are no restrictions on withdrawals or

transfers

  • An additional letter from the person who will be financially supporting the F-1 student demonstrating their willingness and ability to provide adequate support.

8.Proof of insurance coverage

  • If paid by UTHSCSA, proof of coverage is needed for the first three months of employment. This can be a copy of the insurance policy or a letter/email promising to purchase health insurance upon arrival in the U.S.
  • If visitor is not paid by UTHSCSA, insurance coverage is required for the duration of stay.

*Transfer Students & OPT Students must ADDITIONALLY provide:

  • Copies of ALL previously issued I-20’s, I-94 (both sides), U.S. visas, and EAD card (if applicable)
  • F & J Transfer In Clearance Form

*Students currently on other visa statuses must ADDITIONALLY provide:

  • Copies of current visa documents e.g. I-94 (both sides), U.S. visas, passport, etc.

NOTE:

  • Before OIS can issue the I-20, the department must be certain that all student information and current status (accepted officially by UTHSCSA) has been entered into PeopleSoft by the UTHSCSA Registrar’s Office.
  • The department must notify OIS prior to changing the terms and conditions of the F-1 student (e.g. stipend, work-site, responsibilities, work hours, etc.) during the F-1’s appointment period.
  • When the F-1 application packet is completed, OIS will notify the department to pickup the I-20 and Welcome Packet, which will be should be sent immediately to the student by department contact person via express mail service.
  • It is the department’s responsibility to pick up the I-20 from OIS.
  • *It will take approximately 5-10 working days for OIS to produce the I-20*

Should you have any questions regarding the application procedures and

documents, please contact the Office of International Services at 567-6241.