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Wichita State University | International Education | 1845 Fairmount Street | Wichita KS 67260-0122
tele: (316) 978-3232 | fax: (316) 978-3777 | e-mail: iss@wichita.edu
Home Institution Certification Form
J-1 Student Interns
I hereby certify the following information for the above student:
The student is currently enrolled pursuing a post-secondary degree at this institution and is in good
academic standing;
I have reviewed a copy of the Form DS-7002, Training/Internship Placement Plan completed by the
student’s prospective WSU internship supervisor;
The student has the appropriate educational background to participate in the internship;
The internship at WSU will fulfill educational objectives of the student’s current degree program;
The internship will expose the student to American techniques, methodologies, and technology that
will expand upon his or her current knowledge or skills;
The student will be returning to this institution to complete his/her studies upon completion of the
internship program.
Student Intern Information
Passport Surname/Family Name: Passport Given Name:
Date of birth (dd/mm/yyyy): ___ /___ / _____ Male Female
Name of Home Institution:
Address of Home Institution:
Major Field of Study: Degree Level (Bachelor, Masters, etc):
Anticipated Date of Graduation (dd/mm/yyyy): ___ /___ / _____
How will this internship program fulfill the educational objectives of the student’s current degree program?
Dates of Internship (dd/mm/yyyy): ___ /___ / _____ to ___ /___ / _____
Dean/Academic Advisor Certification
Name of Dean or Academic Advisor: Signature:
Email address: Telephone Number:
