REQUEST FORM FOR J-1 VISA CERTIFICATION (Form DS-2019)

Once this request form and the required supporting materials have been received, the Office of International Services (OIS) will prepare the Certificate of Eligibility for Exchange Visitor Visa (J-1) Status within 10 business days. OIS will send the certificate (Form DS-2019) to the inviting department for forwarding on to the exchange visitor along with the department’s formal letter of invitation.

International Scholar Section

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

______

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

2)U.S. Social Security Number (if any): ______- ______- ______

3)Date of Birth: ______/______/______4) Gender: _____ Male _____ Female

(Month) (Day) (Year)

5)Country of Birth: ______

6)City of Birth: ______

7)Country of Citizenship: ______

8)Country of Legal Permanent Residence: ______

9)Last Occupation (Job Title) in Home Country:___ Undergraduate Student

___ Graduate Student

___ Professor

___ Researcher

___ Other (Please Specify) ______

10)Name of institution, agency, organization, or employer referenced in # 9 above:

______

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

Institution: ______From: ___/___/_____ To: ___/___/_____ Mo Day Year Mo Day Year

Full Address: ______

Institution: ______From: ___/___/_____ To: ___/___/_____ Mo Day Year Mo Day Year

Full Address: ______

12)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 I.U. ? _____ Yes _____ No Date: ___ /___ /______(Mo/Day/Year)

13)If in the U.S., what visa status are you currently in? ______

14)Have you ever been in the U.S. on a J-1 or J-2 Visa? _____ Yes _____ No If “Yes” please

indicate approximate dates (beginning and ending dates) ______

15)Have you ever visited, worked at, or taken a course on an I.U. campus?

_____ Yes _____ NoIf “Yes” please indicate approximate dates (beginning and ending dates)

______

16)Will you be accompanied by family?_____ Yes _____ No

17)How many non-U.S. citizen family members will be coming with you? ______

18)Dependent Information (please use this format for all non-U.S. citizen dependents)

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

(Month) (Day) (Year)

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

(Month) (Day) (Year)

Country of Birth: ______

City of Birth: ______

Country of Citizenship: ______

Country of Permanent Residence: ______

19)Funding:

*** IMPORTANT ***

Please provide OIS with documentation for ALL funding sources that will be used to support the exchange visitor’s stay at I.U.

  • Documentation for funding from IU may be included in the departmental letter of invitation.
  • Documentation from other sources should be provided on institutional letterhead with a translation in English.
  • If personal funds will be used to support the exchange visitor’s stay, a personal bank statement can be provided to show proof of the availability of funds.
  • Funding must demonstrate a minimum of $1200 per month for the scholar, $783 per month for the first accompanying dependent, and $300 per month for each additional dependent.

Please note that the exchange visitor may be required to show proof of finances again at the time of application for a U.S. entry visa at the U.S. Consulate.

Funding Source Funding Amount Documentation

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

  • IndianaUniversity(including grants from external sources) $______Yes
  • U.S. Government Agency $______Yes

Name of U.S. Government Agency: ______

  • International Organizations $______Yes

Name of International Organization: ______

  • Government of his/her country $______Yes
  • Binational Commission of his/her country $______Yes
  • All other organizations providing support $______Yes
  • Personal Funds $______Yes

International Scholar Checklist:

Please provide your host department with the following materials so that they can complete the remaining items and formally submit the request to the Office of International Services.

______Completed “International Scholar Section” of this request form.

______Copy of passport ID page

______Copy of all dependent passport ID pages (if dependents are accompanying you)

______Copy of supporting documentation showing proof of finances (for all non-I.U. sources)

Hosting Department Section

20)Duration of Stay at I.U. : From ______/______/______to ______/______/______

(Month) (Day) (Year)(Month) (Day) (Year)

21)Primary activity at I.U. : ___ Professor ___ Researcher ___ Short-term Scholar ___ Specialist

22)Campus where primary activity will take place: ______

23)Departmental or school affiliation at I.U. : ______

24)Specific field or subject of proposed activity at I.U. : ______

25)Faculty host extending invitation to I.U. : ______

Job Title of Host: ______E-mail: ______

Departmental Phone Number: ______

26)Contact information for person at I.U. to whom Form DS-2019 should be forwarded:

Name of Contact: ______E-mail: ______

Departmental Phone Number: ______

Campus Address of Contact: ______

27)How would you like OIS to handle Form DS-2019 when it is ready?

______Send form by Campus Mail to person indicated in # 26.

______Contact person indicated in # 26 and someone will pick form up from OIS.

Hosting Department Checklist

(REQUIRED STEPS)

Please ensure that all of the following items are completed and attached BEFORE mailing this request to OIS:

______Copy of departmental letter of invitation to international scholar

______Copy of passport ID page

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

______Copy of supporting documentation showing proof of finances (for all categories indicated)

Departmental Certification

I understand that all additional materials required by the applicant and the sponsoring department must be received by the international office in order to complete this application.

I understand that federal law restricts the sharing of certain technologies and software with foreign nationals. These rules are complex and substantial penalties may be imposed for violations. If the employee may have access to export controlled technology or software controlled by federal law, the hiring unit should contact the Office of Research Compliance to ensure that all applicable requirements are met.

I certify that the Department/Division will notify the international office if the scholar cannot arrive within 30 days of the start date provided on the DS-2019 document.

I certify that the Department/Division will send the scholar to the international office for check-in and orientation upon arrival.

I certify that the Department/Division will notify the international office when the scholar completes their program at IU.

Signature of Department Chair or Director: ______Date: ______

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