Fill - Free fillable J-1 INTERNS (22 CFR 62.22) REQUEST FOR DS-2019 (Florida Atlantic University) PDF form

Division of Student Affairs ~ International Student and Scholar Services

Boca Raton Campus: 777 Glades Road, SU 214, Boca Raton, FL 33431 Tel. (561) 297-3049 Fax: (561) 297-2446

Davie Campus: Diversity Services (LA-203), 3200 College Avenue, Davie, FL, 33314, Tel. (954) 236-1218 Fax: (954) 236-1123

MacArthur Campus: Diversity Services (SR 139), 5353 Parkside Dr., Jupiter, FL 33458, Tel. (561)799-8698 Fax: (561) 799-8721

Email (all locations): isss@fau.edu

REQUEST FOR DS-2019 (CERTIFICATE OF ELIGIBILITY FOR J-1 EXHANGE VISITORS)

J-1 INTERNS (22 CFR 62.22)

The student intern option is a subcategory under the College and University Student Category through

the Exchange Visitor Program. To request a Form DS-2019 for a prospective international student

intern, departments must submit the application packet to the International Student and Scholar

Services (ISSS) Office at least 60 days prior to the desired internship start date. The information and

documents included in this packet were developed based on existing federal regulations in order to

determine eligibility of prospective internship applicants and suitability of internships offered at FAU.

General Information

• Interns must be currently enrolled and pursuing studies at a post-secondary academic institution outside

the U.S., or must have graduated from such an institution within 12 months prior to the proposed

internship start date.

• Internships are up to 12 months in length without the possibility of extension beyond this period.

• Upon completing the internship program, participants must return to their home country and resume (if

applicable) their academic programs in order to graduate from the post-secondary institution outside the

U.S.

• The internship experience must be at least 32 hours per week with no more than 20 percent of the total

activities consisting of clerical work.

• The program must provide the participants with opportunities to expand upon existing knowledge and

skills, and must expose participants to American techniques, methodologies, and expertise.

• The program must not duplicate the participant’s prior work experience or training received elsewhere.

• Internships may not involve child care, elder care, clinical/medical care, or aviation.

• Additional requirements exist for Hospitality/Tourism and Agriculture-related internships.

• Interns must have on-site supervision in completing daily tasks related to their internship activities.

• Interns must be evaluated on a regular basis, at least once every six months. All evaluations must be

completed and signed by the host faculty prior to the conclusion of the internship program. Copies of the

evaluations must be provided to ISSS.

Application Checklist

__ DS-2019 Request (Part I and Part II)

__ Form DS 7002 (to be completed by the host faculty member) – Training/Internship Placement Plan (the form

can be downloaded at http://www.state.gov/documents/organization/84240.pdf).

__ Interview Report Form

__ English Language Certification Form

__ Academic Status Certification Form

__ Appropriate Funding Documentation

__ Prospective Intern’s Resume or Curriculum Vitae

FAU-ISSS-03_2013

REQUEST FOR DS-2019 (CERTIFICATE OF ELIGIBILITY FOR J-1 EXCHANGE VISITORS)

TO INVITE J-1 INTERNS

PART I: TO BE COMPLETED BY THE SPONSORING DEPARTMENT AT FAU

Department Information

st Department: ________________________________ Host Faculty Member: ________________________________

Campus Address: ________________________________ Phone# __________ Fax# _______ Email: ______________

Primary Supervisor (if different from host faculty member) __________________________________________________

Phone # ___________________ Email: _________________ Fax # ___________________

Document delivery preference: ____ Call for pickup ___ Send by campus mail __

Internship Program Information

rospective Intern’s Name ____________________________________________________________________________

Internship Start Date _______________________ Internship End Date __________________

Physical Location of the Internship (complete address including zip code): ______________________________________

__________________________________________________________________________________________________

Total hours per week (min. 32 required) ________ Hours of clerical activities per week _____

Will this internship include any childcare, medical patient care, aviation, or unskilled labor (yes/no)? ________________

Description of Internship Activities _____________________________________________________________________

__________________________________________________________________________________________________

Funding Information

Financial documentation for the J-1 intern and any accompanying dependents must be provided. Foreign language documents must be

accompanied by a certified English translation. A combination of financial sources can be used to meet the required amount

CATEGORY (Estimated expenses include housing, food,

insurance, transportation, etc.)

J-1 Only

J-1 with Spouse

J-1 with Spouse and

One Child

J-1 with Spouse and Two

or More Children

Monthly Estimated Living Expenses

$1,500

$1,920

$2,170

$2,420

Yearly Estimated Expenses

$18,000

$23,040

$26,040

$29,040

Yearly Estimated Expenses for Spouse: $5,000; Yearly Estimated Expenses for One Child: $3,000; Yearly Estimated Expenses for Two or More Children: $6,000

Type of Funds Name of funding source Amount

Florida Atlantic University ___________________________ ______ per (year, month, etc.) ________

US Government Funds ___________________________ ______ per (year, month, etc.) ________

International Organization ___________________________ ______ per (year, month, etc.) ________

Foreign Government ___________________________ ______ per (year, month, etc.) ________

Binational Commission ___________________________ ______ per (year, month, etc.) ________

Personal Funds ___________________________ ______ per (year, month, etc.) ________

Other ___________________________ ______ per (year, month, etc.) ________

(Explain) ____________________________________________________________________________________

Departmental Approvals

By signing this document, the responsible parties agree that they understand the terms and conditions of inviting the

above-named prospective intern as a J-1 Exchange Visitor and they will fulfill their department obligations in meeting the

internship purpose and guidelines.

Host Professor: ________________________ _________________________ _______________

Name Signature Date

Direct Supervisor _______________________ _________________________ _______________

Name Signature Date

Department Chair______________________ _________________________ ________________

Name Signature Date

Dean: _________________________ ________________________ ________________

Name Signature Date

FAU-ISSS-03_2013

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PART II: TO BE COMPLETED BY PROSPECTIVE INTERN

FAU Department and Contact Person: ___________________________________________________________________

Personal and Academic Information

Name (as it appears in the passport) _____________________________________________________________________

Last/family/surname First/Given Middle Name (if applicable)

Gender: Male ___ Female ___ Date of Birth: _____________ Place of Birth:___________________________

Month/Day/Year City/Province/Country

Country of Citizenship: _____________________ Country of Permanent Residence: __________________________

Residential address in the home country: ________________________________________________________________

_________________________________________________________________________________________________

Telephone: _____________________________ Email: _____________________________ Fax: __________________

U.S. Address (if not available, include department address): _________________________________________________

Highest Academic Degree Received: ____________________ Field of Study ____________ Completion date: ________

Current or Most Recent Employer and Position in country of citizenship or legal permanent residence (if applicable):

__________________________________________________________________________________________________

If currently a student, indicate Post-Secondary Institution Abroad: ______________________________________

Current Academic Degree: ___________________________ Expected Completion Date: _______________________

Field of Study: _____________________________________________________________________________________

J Exchange Visitor Program History

Previous J Exchange Visitor Programs (include time spent in J-2 status): None ______

From _____________ To __________________ Category (student, research scholar, etc.) ___________________

From_____________ To __________________ Category (student, research scholar, etc.) ___________________

Have you ever applied for a waiver of the Two-Year Home Country Residency Requirement? No ___ Yes____

If yes, explain the current status of your application: ______________________________________________________

________________________________________________________________________________________________

Dependent Information (See Part A for Financial Documentation Guidelines)

Provide the following information for all J-2 dependents (spouse, children under 21) who will accompany you in the U.S.

Use a separate page if necessary. List names as they appear in the passport or official national identification documents:

Name

(Last, First, Middle) _______________________________ Relationship: ___ Spouse ___ Child (under 21)

Gender: ___ Male ___ Female Date of Birth: ________________ Place of Birth: ______________________________

Month/Day/Year City/Province/Country

Country of legal permanent residence: ___________________________ Country issuing passport: __________________

Name

(Last, First, Middle) _______________________________ Relationship: ___ Spouse ___ Child (under 21)

Gender: ___ Male ___ Female Date of Birth: ________________ Place of Birth: ______________________________

Month/Day/Year City/Province/Country

Country of legal permanent residence: ___________________________ Country issuing passport: __________________

CATEGORY (Estimated expenses include housing, food,

insurance, transportation, etc.)

J-1 Only

J-1 with Spouse

J-1 with Spouse and

One Child

J-1 with Spouse and Two

or More Children

Monthly Estimated Living Expenses

$1,500

$1,920

$2,170

$2,420

Yearly Estimated Expenses

$18,000

$23,040

$26,040

$29,040

Acknowledgment of Insurance Requirement:

The Exchange Visitor Program requires all program sponsors to notify exchange visitors that they and their dependents

must comply with insurance requirements mandated by the Exchange Visitor Program and by Florida Atlantic University. J-1

Interns must purchase a plan approved by FAU (http://www.fau.edu/isss/current/insurance.php

ACNL

OWLEDGMENT:

I have been notified that I must have medical insurance for myself and accompanying dependents

as stated above. I understand that failure to comply with this requirement may result in termination from the FAU

Exchange Visitor Program and my J-1 intern program.

Name: _________________________ Signature: ________________________ Date: __________________

FAU-ISSS-03_2013

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INTERVIEW REPORT FORM

Prospective Applicants for the Intern Program

J Exchange Visitor Program at Florida Atlantic University

International Student and Scholar Services Office

561-297-3049 ~ Fax 561-297-2446 ~ Email: isss@fau.edu

This form is a required part of the application process for the Intern category under the J Exchange Visitor

Program. The form must be completed and signed by the host faculty member at Florida Atlantic University. If

a written agreement exists between FAU and the prospective intern’s home institution, the form may also be

signed by a representative from the intern’s home university.

1. Name of Student __________________________________________________________________

2. The student was interviewed by ______________________________________________________

(Name)

3. Interviewer’s position: ___ Host Faculty at FAU

___ Representative from intern’s home institution (attach copy of the written

agreement between FAU and home institution)

4. Interview was completed on ______________________________

Month/Day/Year

5. The interview was completed (check appropriate choice):

___ In person ___ By telephone ____ By video/web camera

6. Explain how the internship relates to the intern’s current or recently completed studies:

________________________________________________________________________________

7. Does this person have the adequate academic preparation for the proposed internship?

___ Yes ___ No

8. Explain what specific skills and knowledge the intern will be able to gain from this internship, and how

this internship differs from the intern’s previous internship or training experiences.

_______________________________________________________________________________________

9. Inte

rviewer’s signature ________________________________________ Date: _____________________

10. If the interviewer is from the university abroad, place official university seal or stamp here.

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ENGLISH LANGUAGE PROFICIENCY FORM

Prospective Applicants for the Intern Program

J Exchange Visitor Program at Florida Atlantic University

International Student and Scholar Services Office

561-297-3049 ~ Fax 561-297-2446 ~ Email: isss@fau.edu

This form is a required part of the application process for the Intern category under the Exchange Visitor

Program. Applicants must demonstrate verifiable English language skills sufficient to function on a day-to-day basis in

the internship environment.

1. Nam

e of Student _______________________________________________________________________

English language skills were evaluated by the following method (check the appropriate action below):

2. ___

The FAU host faculty member who conducted the interview and completed the Interview Report Form

Acknowledgment: I certify that I conducted an interview in English with the prospective intern on _______________.

Month/Day/Year

His/her English language skills are sufficient for effective day-to-day functioning in the internship environment.

______________________________________ ___________________________ ___________________

Host Faculty Member’s Name Signature Date (month/day/year)

3.___

A certified English teacher

Acknowledgment: I am/was this prospective intern’s English teacher from _____________ to ________________.

Month/day/year Month/day/year

at ________________________________________________________________________________________

Name of Institution where the English language training took place

His/her English language skills are sufficient for effective day-to-day functioning in the internship environment.

______________________________________ ___________________________ ___________________

English teacher’s name Signature Date (month/day/year)

_____________________________________ ___________________________ ___________________

Email address Telephone Number Fax Number (optional)

4. ___ O

ne of the following standardized language proficiency tests*:

___ TOEFL Written (score) ________________ Minimum score required is 500.

___ TOEFL Computer-based (score) _________ Minimum score required is 173.

___ TOEFLI Internet-based (score) __________ Minimum score required is 61.

___ IELTS (score) ______________ Minimum score required is 6.0

*The minimum scores listed above are the same minimum scores required for admission at FAU. Attach a copy

of the test results.

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ACADEMIC STATUS CERTIFICATION FORM

Prospective Applicants for the Intern Program

J Exchange Visitor Program at Florida Atlantic University

International Student and Scholar Services Office

561-297-3049 ~ Fax 561-297-2446 ~ Email: isss@fau.edu

This form is a required part of the application process for the Intern category under the J Exchange Visitor

Program. The form must be completed and signed by an academic advisor or another authorized representative

from the home institution where the prospective intern is currently enrolled or s/he last attended.

1. Name of Student: _________________________________________________________________________

2. Name of Institution: _______________________________________________________________________

3. Address of Institution: _____________________________________________________________________

4. Institution Website Address: ________________________________________________________________

5. Type of Institution: ___ Post-Secondary ___ Other (explain): _______________________________

6. Is the student currently enrolled at this institution?

a. ___ Yes. Dates of Enrollment: From ___________ to Present

Degree in progress: _________________________________

Expected completion date: ___________________________

b. ___ No. Dates of Enrollment: From: ___________ to _____________

Degree Earned: ____________________________________

c. Field of Study ________________________________________________

7. Will this internship be used to fulfill requirements towards degree completion? ___ Yes ___ No

8. Additional comments:

_______________________________________________________________________________

__________________________________________________________________________________________________

9. Authorized signature:

Name: _________________________________________ Signature: __________________________________

Position: _______________________________________ Date: ______________________________________

Telephone #: ___________________________________ Fax #: ______________________________________

Email address: __________________________________

Place Official University Seal or Stamp Here

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