Fillable EXCHANGE VISITOR REQUEST FORM (Florida Gulf Coast University)

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EXCHANGE VISITOR REQUEST FORM (Florida Gulf Coast University)

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EXCHANGE VISITOR REQUEST FORM
INSTRU C TIO N S: The s pons ori n g FG CU de p art m e n t m ust c o m plet e a l l i t em s on t hi s for m .
Th i s fo r m is to be c om ple t e d a nd a pp r ove d no l e s s than 9 0 day s p rior to exc h a n ge v i s i t or's
ar r i val. P l e ase c o mpl e t e onli n e the n p rint and obt ain signatur e s.
Section 1: FGCU Sponsoring Department Information
a.
Department Name: _________________________________________
b.
Campus Address: _________________________________________________________________________
c. Name of FGCU Host (sponsor) of the Exchange Visitor:
_________________________________________
d. Title:
_________________________________________
e. FGCU Department Address:
__________________________________________________________________
f. FGCU Campus Phone and/or Extension:
_________________________________________
g. Host's Relationship to Exchange Visitor:
_________________________________________
Section 2: Exchange Visitor Information
a. Family Name/Surname:
_________________________________________
b. First/Given Name:
_______________________________
c. Middle Name:
_____________________________
d.
Please check appropriate box:
Begin a new
program
Transfer to FGCU (see Instructions #9)
Extension of program for current scholars – Program start date:
______________________________
Requ es t sh ou ld be ma de a pp roxi m ate ly 30 da ys be fo re c ur ren t DS-2019 fo rm e xp i res.
e.
Please check appropriate box:
Short-term Scholar (1 day to 6 months, no extensions beyond 6
months) Professor (3 weeks minimum to 5 years maximum)
Research Scholar (3 weeks minimum to 5 years maximum)
Specialist (3 weeks minimum to 1 year maximum)
f.
This request covers the period from __________________ to __________________.
(mm/dd/yy) (mm/dd/yy)
g.
Has the exchange visitor held J-1or J-2 immigration status at any U.S. institution in the past 12 months?
Yes
No
5/24/16
Page 1 of 5
ISO:J1EVP/DS2019Requestorm-PartA.E
5/24/16 Page 2 of 5
ISO:J1EVP/DS2019RequestForm-PartA.E
g-1. If YES, give dates/location of all previous J status visits in the past 2 years and attach copies of: previous DS-2019,
current U.S. visa and l-94, passport identification and expiration page). Please contact ISO with any questions.
Dates: __________________
Location: _________________________
Dates:
_________________
Location:
________________________
Section 3: Program Information
a.
Scholar's specific field of study, research, training, or professional activity:
_________________________________________________________________________________________________
b.
Current position (title & institution): ________________________________________________________
c.
Brief description of the program objective the exchange visitor will pursue:
c-1. Specific Objective:
________________________________________________________________________
c-2. Specific Activities:
________________________________________________________________________
c-3. Names of Personnel Involved:
________________________________________________________________
d.
How will the sponsor/department evaluate the exchange visitor's accomplishment of objectives?
(NOTE: The sponsoring faculty/staff member is required to complete program evaluations; evaluations must be
submitted to
ISO for filing to ensure compliance with federal government regulations).
d-1.Approximate Midterm Program Evaluation Date:
________________________
d-2. Approximate Final Program Evaluation Date:
________________________
e.
Does the exchange visitor possess the appropriate credentials and skills to meet the eligibility
requirements of this program?
(ATTACH resume or curriculum vitae; mandatory, must align with program)
Yes
No
f. Does this person have satisfactory English language proficiency (verbal and written), to participate in this program?
Yes
No
g.
How was English language proficiency verified?
English is native language
TOEFL exam
Personal interview
Recommendation by home institution Degree from English language-based institution
Other (explain):
________________________________________________________
h.
Will the exchange visitor wish to enroll in academic courses at FGCU while participating in the Exchange Program? If yes, the
exchange visitor must apply to be a student and be approved by both the sponsoring department and International Services for
student status.
Yes
No
5/24/16 Page 3 of 5
ISO:J1EVP/DS2019RequestForm-PartA.E
Section 4: Off-Site Program
Complete this section if the program will be conducted in full/major part at an off-site location (i.e., not on main FGCU campus).
a.
Location:
_______________________________
b. Supervisor at this location:
____________________________
c. Address:
____________________________________________________________________________________________
d. How will supervision be conducted at this location (ATTACH a letter of support from off-site sponsor, if applicable)?
Section 5: Funding/Financial Support
Funding to support the Exchange Visitor must be documented and verified. Please refer to the "Estimated Costs for
Exchange
Visitors" for current required amounts of funding and acceptable documentation. During the period covered
by
this request,
financial support (in USD) is to be provided to the exchange visitor by one of the following (please check
all that apply and include
USD amounts):
(Note: Invitations to an exchange visitor cannot be issued without the
minimum amounts of financial support as
indicated.)
Florida Gulf Coast University
HAS (OR)
HAS NOT received funding
specifically for the purpose of international
educational exchange
from one or more U.S. government agencies
to support this
exchange visitor
.
If you checked HAS, fill out the information below.
Financial support from organizations other than Florida Gulf Coast University will be provided by one or more of the
following:
U.S. Government Agency (only if support is direct and not through FGCU) $ __________________
International Organization (name of organization):
_______________________________________________ $ __________________
The Exchange Visitor's Government $
__________________
The bi-national Commission of the Exchange Visitor's Home Country $
__________________
All other organizations providing support:
___________________________________________________________ $ __________________
___________________________________________________________
Personal Funds (attach bank statement with USD equivalency) $
__________________
Other: _______________________________________________
$
__________________
TOTAL
$
__________________
5/24/16 Page 4 of 5
ISO:J1EVP/DS2019RequestForm-PartA.E
Section 6: Medical Insurance
All J-1 exchange visitors are required by the U.S. government to have medical insurance which meets the established
minimum criteria
for the visitor and J-2 dependents for the full duration of time
in
the U.S. in the J visa status.
If
an exchange visitor willfully fails to
maintain this insurance, we are required by U.S. government regulations to terminate the visitor's J program status and report to the
Department of State. FGCU sponsoring departments are expected to assist
the exchange visitor in meeting this requirement. Please refer to
the "Exchange Visitor Insurance Requirement" document for more detailed information.
The exchange visitor's health insurance will be paid for by this department for:
Exchange visitor only Exchange visitor and dependents
By checking the box below, I acknowledge that it is the responsibility of the exchange visitor to secure coverage through an independent
insurance provider OR be covered by contract as a FGCU
employee.
I accept and acknowledge these terms.
Section 7: EV Program Limitations and Responsibilities
Please refer to "Exchange Visitor/Scholar Eligibility, Categories, and Related Requirements" and "Instructions for FGCU
Departments to
Host Foreign National Exchange Visitors" on detailed limitations and responsibilities regarding the
Exchange Visitor program at FGCU. By
checking the box below, the sponsoring unit acknowledges they have read and understood the conditions that apply to the exchange visitors.
I have read and understood these conditions and acknowledge the responsibilities associated with the FGCU Exchange Visitor program.
Section 8: Human Resources Approval – If Scholar will be FGCU employee
a.
FGCU position title of the exchange visitor: _______________________________________________
All appropriate administrative processes have been/are being completed according to FGCU Human Resources
guidelines. (For OPS
positions, the OPS Appointment Form must be completed and submitted to HR. For established, advertised positions the appropriate
Appointment Form must be completed and submitted to HR and the Official Offer
Letter generated and executed.)
b.
FGCU HR representative's signature:
_______________________________________________
Date: _________________
Section 9: Attachments
Please submit the following support documents attached to this request. Mark the box for each item attached.
Resume or Curriculum Vitae (Mandatory)
Previous DS-2019, if applicable
Copy of current visa, if applicable Copy of current I-94, if applicable
Letter of invitation from department or HR
Letter from off-site host, if applicable
5/24/16
Page 5 of 5 ISO:J1EVP/DS2019RequestForm-PartA.E
Section 10: Department Approvals - Signatures
As the department sponsor of this exchange visitor, I hereby attest that the information included in this application is
correct to
the best of my knowledge and that the scholar's curriculum vitae was reviewed for appropriateness of
background and meets
the eligibility requirements. Additionally, I ensure that information needed by International Services in administering this program
will be provided as requested.
________________________________________ _________________________________________ ________________
a.
FGCU Faculty/Staff Sponsor/Title (Typed)
Signature
Date
__________________________________________ ___________________________________________ _________________
b.
Department Chair (Typed) Signature Date
__________________________________________ ___________________________________________ _________________
c. College /Division Dean (Typed) Signature Date
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EXCHANGE VISITOR REQUEST FORM (Florida Gulf Coast University)

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Completed 23 July 2020

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