Beloit College Office of International Education
J-1 Exchange Visitor DS-2019 Request Checklist
To request a DS-2019 for a visiting J-1 scholar, please submit the following completed
documents to Shannon Jolly at the Office of International Education (Box 134) or by
email at
Departmental Request to Host J-1 Exchange Visitor (included in this file)
J-1 Scholar Proof of English Proficiency form (included in this file)
Supporting Document(s) demonstrating English Proficiency as listed on the
Copy of Invitation/Appointment Letter from Beloit College
Copies of financial support documents (letter(s) from sponsoring organizations
and/or personal bank statements)
Copies of passport information page(s) for Exchange visitor and any
accompanying dependents
Beloit College Office of International Education
Departmental Request to Host J-1 Exchange Visitor
Section 1: Hosting Faculty/Department Information
Contact Name
Section 2: Exchange Visitor Biographical Information
Please also attach a copy of the biographical information page of the Exchange Visitor’s Passport
Family Name(s)
Given Name(s)
Male Female
Preferred Name (if applicable)
Date of Birth (mm/dd/yyyy)
City and Country of Birth
Country of Legal Permanent Residence
Country of Citizenship
Permanent Address in Home Country:
Current Email Address:
Will the Exchange Visitor be accompanied by a spouse or dependent children (under age 21)?
Yes (Please provide copies of the passport information pages for each dependent)
Section 3: Exchange Visitor Background Information
Current Position in Home Country (e.g. Professor at Henan University, China)
Subject Field (e.g. Education, Biology)
Highest Degree Obtained
Section 4: Exchange Visitor U.S. Activity Information
J-1 Category Requested (select one)
Short Term Scholar
Research, observation, lecture, or other related activities not to exceed 6 months. Not subject to 12
month or 24-month bar, but activities may not be extended beyond 6 months.
Primary activity is teaching and/or lecturing. Duration of three weeks to 5 years; Initial stay may
be extended within maximum duration. Subject to 12 month and 24 month bars.
Research Scholar
Primary activity is conducting research. Duration of three weeks to 5 years; Initial stay may be
extended within maximum duration. Subject to 12 month and 24 month bars.
Anticipated Start Date: Anticipated End Date
Exchange visitor may arrive in the United States a maximum of 30 days before program start date
Purpose of Exchange:
Please provide a brief description (1-2 sentences) of the primary responsibilities and activities for
the period the EV will be at Beloit College and the primary field of study
Examples: Exchange Visitor will conduct research in the field of Education comparing the
differences in teaching methods in American and Chinese classrooms.
Exchange Visitor will teach courses in Biology
Primary location of activity (If on campus indicate Department and Building, If off Campus list Physical
Section 5: Exchange Visitor Funding
Please list all sources of funding for the duration of the Exchange Visitor’s program. The Exchange
Visitor must document that he/or she has access to sufficient funding to meet minimum expenses for the
duration of his/or program. Minimum funding requirements are:
$1,100/ month/ individual
$550/month for spouse
$275/ month per each child
$1,000/ initial adjustment expenses
These estimates do not include the cost of mandatory health insurance ($60-$300/month)
Funding Source
Name of Agency (if applicable)
Amount of Funding
Beloit College
International Organization
U.S. Government Agency*
Exchange Visitor’s Government
Other organizations
Personal or Family Funds
*Please categorize funding by the U.S. Government only if the Exchange Visitor receives funds directly from a
U.S. government agency. When individuals are supported through U.S. government funds paid to a Beloit college
professor, department or grant, this is not considered to be direct government funding.
Please provide copies of funding letters and/or bank statements to support each funding source
that the Exchange Visitor will be utilizing.
Section 6: Health Insurance
All J-1 Exchange Visitors and their accompanying J-2 dependents must obtain health insurance for the
duration of their stay that meets certain minimum requirements
Medical benefits per accident or illness: $100,000
Repatriation of remains: $25,000
Medical evacuation: $50,000
Maximum Deductible per accident or illness: $500
The exchange visitor will be purchasing his/her own insurance (must provide proof at time of
check-in with OIE)
The department or the college will be purchasing health insurance for the exchange visitor
Note: The college health insurance plan does not meet the Medical evacuation and
repatriation requirements. Additional insurance would be needed to cover this.
Host Faculty/Department Authorization
Host Faculty/Department Signature Date
Please submit this form and the following supporting documents to Shannon Jolly in the Office of
International Education (Box 134) or by email to:
Funding Documentation (copy)
Copy of Passport Information Page(s) for
Exchange Visitor and any dependents
Appointment or Invitation Letter (copy)
Proof of English Proficiency Form and
Supporting Document(s)
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Beloit College Office of International Education
J-1 Scholar Proof of English Proficiency
Effective January 5, 2015, a revision to the U.S. Federal Regulation for Exchange Visitors under 22
C.F.R. Part 62 Subpart A mandates that prior to issuance of the form DS-2019 Certificate of
Eligibility, Exchange Visitor Program Sponsors must establish and document that:
The exchange visitor possesses sufficient proficiency in the English language, as
determined by an objective measurement of English language proficiency, successfully to
participate in his or her program and to function on a day-to-day basis. A sponsor must
verify an applicant’s English language proficiency through a recognized English language
test, by signed documentation from an academic institution or English language school, or
through a documented interview conducted by the sponsor either in-person or by
videoconferencing, or by telephone if videoconferencing is not a viable option.” (22 C.F.R.
To Be Completed by Sponsoring Department/Faculty
The following documentation is being submitted with this form as evidence of English
Language Proficiency for incoming J-1 Scholar:
(Name of Scholar)
Note: Only one form of documentation is necessary
Copy of test scores for the Test of English as a Foreign Language (TOEFL) or
International English Language Testing System (IELTS) scores from within the last 5 years
Copy of diploma, transcript or completion certificate as evidence of successful
completion of a course of study taken at an institution in which English is the primary
language of instruction
Letter from an English language instructor at an academic institution in the U.S. or
elsewhere who knows the applicant and can certify that the applicant has a sufficient level
of English proficiency to:
Be able to communicate with students in the classroom (instructional
positions only)
Be able to carry out other responsibilities associated with the position
Be able to navigate daily living tasks in English
Statement from Christina Eddington, Beloit College ESL Instructor, to certify completion
of video chat to assess English language proficiency
This individual is a Native speaker of English
Sponsoring Faculty Signature Date
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