Fillable J1 Schol Request For Visa

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J1 Schol Request For Visa

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Request for J-1 Visa Document
Center for International Programs
The purpose of the J-1 exchange visitor visa for professors, research scholars, student interns, and short-term
scholars is to facilitate international collaborative teaching and/or research activities. Visitors are invited to the
U.S. for a program with a specific objective and length of stay not to exceed five years. Scholars who have held a J
status for a period of longer than six months are not eligible for a new J program until one year following the end
of their original program, and potentially for two years if in the Professor/Research Scholar category. If you have
questions about the eligibility for J-1 status, please contact Tim Kao at tkao1@udayton.edu
prior to submitting this
form.
To ensure that your visitor will be able to arrive on schedule, this form should be completed two
months prior to
the anticipated start date to allow adequate time for processing the DS-2019 forms and obtaining the visa abroad.
If the visitor will be paid by UD, Human Resources and Affirmative Action will need to be consulted, and regular
hiring procedures (e.g. PAF processing) will need to be completed in tandem with this request for visa documents.
PART I: INFORMATION NEEDED TO COMPLETE DS2019
Surname: ______________________ Given/First name: ________________ Middle name: __________
Male Date of City of Country of
Female birth (mm/dd/yy): _________ birth: ______________ birth: _____________________
Country of Country of legal permanent residence
Citizenship: _________________________ (if other than the country of citizenship): ___________
Visitor’s position in Private
Home country: _______________________________________ Government
Will family members Yes (If yes, complete the Dependent Information section of this form)
accompany the exchange visitor? No
Has the scholar participated in a J-1 Yes (If yes, provide dates and location of all previous J programs)
or J-2 program in the last 24 months? No
Please identify appropriate Professor/Research Scholar (< 5 yr appointment, non-tenure track)
Classification for your visitor (only one) Short-term Scholar (≤ 6 months to guest lecture/consult/collaborate)
Student (Exchange student)
Student Intern (Please complete Part XI J-1 Intern section of this form)
Specialist (< 1yr, to observe/demonstrate/consult as expert in field)
Program dates (mm/dd/yy): Start: ________________________ End: ____________________________
Description of primary activity of visitor: ___________________________________________________
PART II: COMPLETE ONLY IF VISITOR IS ALREADY IN USA
Current Date of Attach copy of visitor’s I-94 card, passport, and
Visa Status: _____________ Entry: ____________
DS2019 form
PART III: FUNDING SOURCES/SPONSORSHIP
A minimum of $15,000/year for your visitor, $7,500/year for spouse, and $5,000/year for each child must be documented. A
letter or bank statement must be provided as evidence of sponsorship. Please follow HR/AA procedures for any paid activity.
UD salary Is funding certain for Yes
Or stipend: ____________________ the amount of time requested? No
Other funding Funding Private
(In $US): ______________________ Source: __________________ Governmental
Request for J-1 Visa Document
Center for International Programs
PART IV: DEPARTMENT & VISITOR CONTACT INFORMATION
Primary UD host Primary UD host
Department: ___________________ contact person: ______________________________________
Please include the letter of invitation with this request form. It should reference anything that is being provided to the exchange
visitor (i.e. stipend/salary, office space, housing/parking/email/ room/board) and purpose of visit.
Who will be providing the letter of invitation: _______________________________________________
Exchange Visitor mailing address:
Street: _______________________ Apt/House# __________________ City: _______________
State/Territory: ________________ Country: _____________________ Postal Code: _________
Exchange Visitor Contact information:
Home telephone: 011-____- ___________________ Fax: 011-____-___________________
Email address: ________________________________________________________________________
PART V: INFORMATION NEEDED TO ENSURE J-1 REGULATION COMPLIANCE
All J-1 exchange visitors and their dependents are required to have health insurance. In some cases,
exchange visitors may be covered by UD health insurance. Please indicate how the exchange visitor will
meet this requirement:
Visitor will be responsible for health insurance costs
UD host will enroll visitor in UD plan
UD host department will cover insurance costs through foreign scholar’s plan
PART VI: REQUIRED FOR SUBMISSION
Please submit the following documents, along with this request form, to Tim Kao, +0315:
Original letter of invitation for visitor (includes program objectives, period of duration and funding
source information, along with what will be provided in kind to exchange visitor)
Copy of visitor’s CV or Résumé
Documentation of funding [Originals, from source(s) of sponsorship]
Information on dependents accompanying exchange visitor
Copy of current visa documents (if already in the USA)
Copy of passport (biographical page)
PART VII: RESPONSIBILITIES
By signing this form, you agree to do the following:
1. Assist your exchange visitor in checking in with Tim Kao for orientation information within three
days of arrival.
2. Encourage your visitor to participate in the academic and social activities of your unit as well as
cross-cultural activities on the campus and in Dayton.
3. Notify Tim Kao when your exchange visitor:
a. Completes his/her program
b. Changes his/her program activity/purpose
c. Needs to terminate his/her program
d. Changes address while in the USA
PART VIII: INTERNATIONAL SCHOLAR HOUSE REQUEST
UD offers an International Scholar House residence to welcome key international faculty and scholars to campus.
Scholars who are part of a planned international initiative or from a partner institution will be eligible for the house
should the stay be at least one week to no longer than one academic year. The cost is $350/month (which may be
prorated). CIP will coordinate placements in the International Scholar House and will notify guest scholars and
hosts upon approval of housing request.
Request for J-1 Visa Document
Center for International Programs
Arrival date: ___________________________ Departure date: __________________________
Responsible for payment: Exchange visitor UD Host (Account to be billed: __________)
Please confirm eligibility:
Scholar represents part of a planned initiative or partner institution
Scholar will be visiting UD for more than one week, but less than one academic year
Approval of Dean’s Office Required:
Title: ____________________________________ Date: ____________________________
Signature: __________________________________________________________________________
PART IX: PROGRAM APPROVAL & AUTHORIZED SIGNATURES
Please verify that the information contained in this form is correct and confirm your agreement with the responsibilities outlined
in Part VII. Your signature verifies that this exchange visitor’s program is to support international collaborations in research
and/or teaching and that funding is guaranteed for the period of time requested.
UD Host Signature: ________________________________________________ Date: _______________
Host Department: __________________________________________________
Approval of Dean’s Office Required:
Title: ____________________________________ Date: ____________________________
Signature: __________________________________________________________________________
PART X: DEPENDENT INFORMATION (IF APPLICABLE)
SURNAME: __________________ FIRST NAME: __________________ MIDDLE NAME: _____________
DATE OF BIRTH (MM/DD/YY): _________ MALE FEMALE
RELATIONSHIP TO VISITOR:______________________________________________________
CITY AND COUNTRY OF BIRTH: ___________________________________________________
COUNTRY OF CITIZENSHIP: ______________________________________________________
COUNTRY OF PERMANENT RESIDENCE: ____________________________________________
SURNAME: __________________ FIRST NAME: __________________ MIDDLE NAME: _____________
DATE OF BIRTH (MM/DD/YY): _________ MALE FEMALE
RELATIONSHIP TO VISITOR:______________________________________________________
CITY AND COUNTRY OF BIRTH: ___________________________________________________
COUNTRY OF CITIZENSHIP: ______________________________________________________
COUNTRY OF PERMANENT RESIDENCE: ____________________________________________
SURNAME: __________________ FIRST NAME: __________________ MIDDLE NAME: _____________
DATE OF BIRTH (MM/DD/YY): _________ MALE FEMALE
RELATIONSHIP TO VISITOR:______________________________________________________
CITY AND COUNTRY OF BIRTH: ___________________________________________________
COUNTRY OF CITIZENSHIP: ______________________________________________________
COUNTRY OF PERMANENT RESIDENCE: ____________________________________________
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Request for J-1 Visa Document
Center for International Programs
PART XI: TO BE COMPLETED FOR J-1 STUDENT INTERN CATEGORY ONLY
All student interns must be paid by UD, a third-party entity such as home government, institution, or private organization, or be
participating in an approved internship exchange agreement on file with UD. Most internships do not include enrollment in UD
courses. If this placement requires enrollment, please consult with CIP. Additionally, internships
require a written student
evaluation prior to departure of the student. It is the responsibility of the host to provide a copy of this evaluation to Tim Kao in
order to comply with J-1 regulations in this category.
If you are able to answer “yes” to all of the following questions, then the student qualifies for the J-1
Student Intern category sponsored by UD:
YES NO
1. Is the prospective student intern currently an undergraduate student in good
academic standing at a foreign university?
2. Is the student coming to the US to pursue a structured, work-based internship
program that fulfills educational objectives for his/her specific academic field?
3. Will the internship provide non-clinical, experience-based learning?
Note: Patient care or contact (any work providing therapy medication or other clinical or medical care, child or elder care) is not
permitted in this category.
4. Will the internship be full-time (at least 32 hours/week)?
5. Will the internship have no more than 20% of the time devoted to clerical tasks?
6. Will the student return to his/her prior academic studies following the completion of
the internship program and fulfill the degree requirements thereof?
7. Does the student have verifiable English skills sufficient to function on a day-to-day
basis in the internship environment?
8. If the internship is unpaid, does the student have sufficient funds to cover living
expenses (approx. $1250/month of stay)?
9. Will the student not be enrolled in classes?
10. Will the intern not displace any temporary or permanent U.S. workers (part or full
time)?
FINANCIAL INFORMATION FOR INTERNSHIP
A minimum of $1250 per month to cover basic rent, food, transportation, health insurance and
miscellaneous expenses must be documented.
Intern will be provided a salary/stipend from UD (Account #: ___________ Amount: $___________)
Intern will be funded by private institution (Source: _______________________________________)
Intern will be funded by a government (Source: __________________________________________)
REQUIRED FOR J-1 STUDENT INTERN SUBMISSION
• Verification letter from home institution. Will verifying good academic standing and that the
internship will fulfill an educational component in the degree program being pursued.
• Documentation of funding from funding source. Acceptable documents: affidavit of support,
scholarship, or bank statement. Amount needed: $1250 per month (min).
• Proof of English proficiency. Acceptable documents: official TOEFL or IELTS score report or letter
from home institution testifying the intern’s English proficiency.
• Proof of health insurance. State Department mandates minimum coverage shall provide:
o medical benefits of at least $50,000 per accident or illness;
o repatriation of remains in the amount of $7,500;
o expenses associated with medical evacuation of the exchange visitor to his or her home country in the amount of $10,000;
and
o a deductible not to exceed $500 per accident or illness.
• DS-7002 filled out by UD Host. State Department form
(http://www.state.gov/documents/organization/84240.pdf
)
Request for J-1 Visa Document
Center for International Programs
• Copy of passport (biographical page)
• Letter of invitation from UD host
Please print and submit completed visa request and all required support documents to:
Tim Kao, ARO| Rike Center, Room 204|Campus Mail Zip: +1701|Fax: 229-2766 tkao1@udayton.edu
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J1 Schol Request For Visa

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Completed 17 November 2019

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