Fillable JEV Application Prof Spec Scholar 06 01 12 (Valencia College)

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JEV Application Prof Spec Scholar 06 01 12 (Valencia College)

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Updated: 05/10/2011
J Exchange Visitor PROGRAM
APPLICATION PACKET
PROFESSOR, SHORT-TERM SCHOLAR, SPECIALIST
DESIGNATIONS
TABLE OF CONTENTS
Application Checklist 2-3
DS-2019 Request Form 4
Dependent Information Form 5
Certification of Finances Form 6
Sponsor’s Certification Form 7
Affidavit of Living Expense Form 8
Exchange Visitor Responsibilities Form 9
Information Release Form 10
Injury & Sickness Insurance Form 11
ORLANDO, FLORIDA, U.S.A.
2
Steps to Process a Professor, Specialist, or Short-Term Scholar Application:
Use the following checklist to ensure that you submit a complete application packet. Check off each item as it is completed.
_____ Step 1: Ensure that you meet the English language proficiency requirements for your program application: A TOEFL score
of 64 or higher (Internet version), 180 (computer version), or 480 (paper version); or score a 7 or higher on the
International English Language Testing System (IELTS). You may also submit a curriculum vitae, a writing sample,
or participate in a telephone interview to determine your proficiency level in lieu of testing.
_____ Step 2: Have your hosting department at the College complete the Hosting Department Sign-Off Form and submit a copy
of this form to the Study Abroad and Global Experiences office (DTC-2). Your College liaison will let you know if
the request has been approved. NOTE: If you will be teaching for Valencia, you must meet the hiring
requirements for the position.
_____ Step 3: Review the U.S. State Department’s website (http://www.state.gov/travel/) for any special regulations governing
all travel procedures for your country. Please note that security clearances can take several months.
_____ Step 4: Complete the J Exchange Visitor Program Application Packet:
_____ Step 5: Submit this JEV Application Packet to the Responsible Officer listed on the next page.
_____ Step 6: Once all JEV application documents are received and your online application is completed, you will:
Be issued Form DS-2019 along with the J Exchange Visitor Pre-Arrival Information Packet.
If you would like these documents sent by expedited shipping, you must include a telephone number, credit
card number, and expiration date on the "Shipping Agreement" section of the DS-2019 Request Form.
Be notified of your program approval by email.
_____ Step 7: Review the J Exchange Visitor Pre-Arrival Information Packet thoroughly as it will help you through the process
of applying for your visa, making housing arrangements, and preparing for your trip to Orlando, Florida.
continued next page...
DS-2019 Request Form: Complete and sign the form.
Dependent Information Form (if applicable): A separate DS-2019 will be issued for each eligible dependent.
Certification of Finances Form: If your program duration is different than what is listed, use a monthly average.
Include an original bank letter on official bank letterhead not more than 30 days old. It must show the funds to
support your entire program duration, be written in English, and converted to current American dollars.
Affidavit of Living Expenses: If you will not be paying room and board, have your host complete this form. It must
be notarized.
Sponsor’s Certification Form: Your program sponsor (the individual or entity funding your program) must complete
this form.
Exchange Visitor Responsibility Form: Read and sign this form.
Information Release Form (if applicable): Complete and sign this form if you have someone in the U.S. assisting
you in this process who will be submitting or picking up documents on your behalf,
Injury and Sickness Insurance Payment Options Form: Follow the instructions on the top of the form.
Include a clear copy of the photo page and issue/expiration page of your passport.
Submit proof of English language proficiency.
Application Checklist
3
Steps to Register (continued):
_____ Step 8: Pay the J-1 I-901 SEVIS Fee of $180 online at: https://www.fmjfee.com/i901fee/. You must print a copy of the paid
receipt for your embassy appointment.
_____ Step 9: Make an appointment with the U.S. Embassy in your home country to get the J-1 visa.
_____ Step 10: After your visa request has been approved, make your housing and transportation arrangements for your stay in
Orlando.
Upon arrival to the United States (you cannot arrive more than 30 days prior to your program start date):
Check in with your College liaison in your hosting department to review the
program schedule and obligations.
Check in with the College’s Responsible Officer.
Pay for your Injury and Sickness Insurance at the campus Business Office.
Obtain a Valencia ID number.
Request your parking decal through your Atlas account.
If you will be receiving a payment for any services rendered, be sure that
you obtain your Vendor VID number. You must submit an invoice in order to
get paid. Contact the Procurement Department if you have any questions.
Attend the manadatory J Exchange Visitor Orientation.
Valencia College Contacts
Ms. Bliss Thompson
Counselor, International Student Services
Responsible Officer (RO)
Office: (011) 407-582-1561
Email: bthompson@valenciacollege.edu
West Campus
1800 South Kirkman Road
Orlando, Florida 32811
Ms. Jennifer Robertson
Director, Study Abroad & Global Experiences
Alternate Responsible Officer (ARO)
Office: (011) 407-582-3404
Cell: (011) 407-967-5888 (for emergencies only)
Email: jrobertson@valenciacollege.edu
Downtown Center
2nd Floor
190 S. Orange Ave.
Orlando, Florida 32809
Application Checklist
4
Today's Date (mm/dd/yyyy): _________________________________
Designation Type: Application Type:
Professor (3 weeks to 5 years) First-Time Participant Dependents will be coming
Short-Term Scholar (1 day to 6 months) Transfer In I will be a paid vendor
Specialist (3 weeks to 1 year) Change of Status
Applicant Information: Please print your name as it appears on your passport.
Family Name: _____________________________________ First Name: ___________________ Middle Name: ___________
Date of Birth (mm/dd/yyyy): __________________________ Gender: Male Female
City of Birth: ______________________________________ Country of Birth: ____________________________________
Country of Citizenship: ______________________________ Country of Permanent Residency: ________________________
Email Address: ____________________________________ Employment Status in Home Country: _____________________
Emergency Contact Name, Phone, & Email: _____________________________________________________________________
Exchange Program Information: (if applicable—be sure to include a copy of your Learning Agreement)
Program of Study: _________________________________________________________________________________________
Estimated Arrival Date: __________________ Program Start Date: __________________ End Date: _____________________
Home Institution: ______________________________________________ Country: ________________________________
Home Institution Contact Name: __________________________________ Contact Email: ___________________________
Overseas Contact Information: U.S. Contact Information: (if available)
Phone Number: ___________________________________ Phone Number: __________________________________
Email Address: ___________________________________ Email Address: ___________________________________
Address Line 1: ___________________________________ Address Line 1: ___________________________________
Address Line 2: ___________________________________ Address Line 2: ___________________________________
Address Line 3: ___________________________________ Address Line 3: ___________________________________
City: ___________________________________ City: ___________________________________
State/Province: ___________________________________ State/Province: ___________________________________
Country: ___________________________________ Country: ___________________________________
Shipping Agreement: Please read and sign.
I understand that Valencia will mail my DS-2019 by regular mail services. Should I require expedited shipping of my packet, I agree
to pay for all applicable shipping costs with the credit card number provided below. Should this credit card be declined, I understand
that it is my responsibility to provide the college with another credit card and that this might delay the shipping process.
_____________________________ __________________________ __________________________
Exchange Visitor's Signature Date Telephone Number
_________________________________ __________________________ _________________
Credit Card Number Expiration Date Security Code (3 or 4 digit code)
Valencia accepts the following credit cards: Visa, Master Card, American Express, Discover
DS-2019 Request Form
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If any of your family members (spouse and/or children) will be accompanying you to the United States and will be applying
for a J-2 dependent visa, please complete the following information. A separate DS-2019 will be issued for each eligible
dependent.
Dependent 1:
Family Name: _________________________________ First Name: ___________________ Middle Name: ___________
Date of Birth (MM/DD/YYYY): _____________________ Gender: Male Female
Country of Birth: ________________________________ Country of Permanent Residency: _________________________
Country of Citizenship: ___________________________
Relationship to J Exchange Visitor: Spouse Child
Have you been on J-1 status before? Yes No If yes, when: _________________ For how long?: ___________
Dependent 2:
Family Name: _________________________________ First Name: ___________________ Middle Name: ___________
Date of Birth (MM/DD/YYYY): _____________________ Gender: Male Female
Country of Birth: ________________________________ Country of Permanent Residency: _________________________
Country of Citizenship: ___________________________
Relationship to J Exchange Visitor: Spouse Child
Have you been on J-1 status before? Yes No If yes, when: _________________ For how long?: ___________
Dependent 3:
Family Name: _________________________________ First Name: ___________________ Middle Name: ___________
Date of Birth (MM/DD/YYYY): _____________________ Gender: Male Female
Country of Birth: ________________________________ Country of Permanent Residency: _________________________
Country of Citizenship: ___________________________
Relationship to J Exchange Visitor: Spouse Child
Have you been on J-1 status before? Yes No If yes, when: _________________ For how long?: ___________
Dependent 4:
Family Name: _________________________________ First Name: ___________________ Middle Name: ___________
Date of Birth (MM/DD/YYYY): _____________________ Gender: Male Female
Country of Birth: ________________________________ Country of Permanent Residency: _________________________
Country of Citizenship: ___________________________
Relationship to J Exchange Visitor: Spouse Child
Have you been on J-1 status before? Yes No If yes, when: _________________ For how long?: ___________
Dependent Information Form
6
This confidential financial certification form MUST be completed before the DS-2019 will be issued. Supporting financial
documents must be originals and can be no more than 30 days old from the date of application or reapplication. If you have
any questions about completing this form, contact the Responsible Officer listed on page 3 of this packet.
Family Name: ______________________________________ First Name: ___________________ Middle Name: ___________
Phone: ___________________________________________ Email Address: _______________________________________
The following information gives the fees for the program duration defined below. Please note that there is a $180
SEVIS FEE in addition to the amounts listed below. You must show financial support for the entire program duration.
Use the amounts below to calculate the total amount of funding required. Enter your program duration, the projected
expenses, and the total into the table below. Do not include expenses that you will not incur.
*Prices are subject to change.
Financial Support in U.S. Dollars:
Enter your funding sources, the sponsor names, and the funding amounts below. The total should match the total you
entered in the table above.
Enclose a signed copy of a Sponsor’s Certification Form for each award for numbers 2 through 4 below.
1. Personal Savings Amount: $ ______________________
2. Sponsor #1: _____________________________ Funds Amount: $ ______________________
3. Sponsor #2: _____________________________ Funds Amount: $ ______________________
4. Sponsor #3: _____________________________ Funds Amount: $ ______________________
5. Valencia College Sponsorship Amount: $ ______________________
TOTAL $_______________________
Certification of Finances Form
Program Duration 1 Week 1 Month 1 Semester
(5 months)
1 Year
Injury and Sickness Insurance* $ 17 $ 68 $ 340 $ 884
Living expenses $ 324 $ 1,295 $ 5,180 $15,541
Transportation (car rental) $ 150 $ 600 $ 3,000 $ 6,000
Social and cultural activities $ 50 $ 200 $ 800 $ 1,600
Total Financial Requirement:
$ 541 $ 2,163 $ 9,320 $ 24,025
$ 0.00
0.00
7
TO BE COMPLETED BY EXCHANGE VISITOR’S FINANCIAL SPONSOR. This can be a parent, relative, friend, agency, or
educational institution.
Date: ________ / ________ / ________
month day year
Exchange Visitor’s Name: ______________________________________________________
Sponsor’s Name (person or institution) ______________________________________________________
Relationship to Exchange Visitor: ______________________________________________________
Address Line 1: ______________________________________________________
Address Line 2: ______________________________________________________
Address Line 3: ______________________________________________________
City / State or Province / Country: ______________________________________________________
Phone/s: ______________________________________________________
Email: ______________________________________________________
This is to certify that __________________________________________ will provide the financial support for the Exchange
(Sponsor’s Name)
Visitor listed above from _______________________ to _______________________ in the amount of $__________________.
(Start Date) (End Date) (U.S. dollars)
These funds will pay for the fees described in the Certification of Finances From. Enclosed is a bank letter or statement from my
financial institution.
______________________________________________
Authorized Name
______________________________________________
Signature
______________________________________________
Date
Sponsor’s Certification Form
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8
TO BE COMPLETED BY THE LANDLORD, PROPERTY OWNER, OR HOST IN ORLANDO, FLORIDA: By completing this
affidavit, you are swearing to the U.S. government that this individual will receive free room and board for the duration of
his/her program. You cannot require any type of service to be performed in exchange for this benefit. You are also proving
that you are the person who owns or rents the property and can afford the support you are promising.
SWORN STATEMENT OF LIVING EXPENSES
I, ___________________________________________, promise that _______________________________________ and
(Landlord, Property Owner, or Host’s name) (Exchange Visitor's name)
________________________________________________________, will live free of any charge in my home for his/her
(Dependent/s' names if applicable)
period of study at Valencia College.
Relationship to the Exchange Visitor: ___________________________________________________________________________
Home Address: __________________________________________________________________________________________
City: ____________________________________ State: ________ Zip Code: _______________
Home Phone: _____________________________ Cell Phone: ____________________________________
Email Address: ____________________________________________________________________________
I understand that this is a legal document. By signing and notarizing this paper, I am liable for providing this individual with
a place to live free of charge for room and food for the duration of his/her Exchange Visitor Program. I will not require any
type of compensation or service for this benefit.
Included is a copy of my rental agreement or rent receipt.
Included is a copy of my deed of ownership or my residence tax bill.
I swear that the information I have provided above is true and correct:
___________________________________________________
Signature of Landlord/Property Owner/Host
___________________________________________________
Sworn and suscribed before me this day
___________________________________________________
Signature of Notary
Affidavit of Living Expenses
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All Exchange Visitors are responsible for learning, understanding, and complying with United States federal laws and
regulations governing the J visa. Failure to do so will violate the Exchange Visitor’s legal status in the U.S. Please read the
information below. Then sign and date the form and submit it with your registration packet. If you have any questions
about completing this form, contact the Responsible Officer.
As an Exchange Visitor, my responsibilities include but may not be limited to the following items listed below:
 Upon arrival to the United States, check in with your RO/ARO and get registered in SEVIS.
 Retain required documentation at all times which include a valid DS-2019, I-94 card, and valid passport during the entire
length of the program.
 Engage only in appropriate activities permitted, specifically in Section 4 of the DS-2019.
 Report address changes to your assigned RO/ARO within 10 days of the move date.
 Maintain the required sickness and injury insurance coverage for the entire program period (including program extensions).
You must purchase the College's policy for yourself and any dependents in J-2 status.
 Comply with employment guidelines and refrain from any unauthorized employment. All employment activity that is not
included in Part 4 on the DS-2019 must be approved in writing by the RO/ARO before the activity begins. Students may
only work at the designated internship site and be “in good standing” with their employer.
 Report any proposed program changes to the RO/ARO in advance.
 File timely and appropriate school transfer or program extension requests with the corresponding department.
 Obtain a travel signature on the DS-2019 from the RO/ARO prior to departing the United States anytime during your
program duration. Please note that exchange visitors may not be allowed to re-enter the U.S. without travel authorization.
 Comply with all academic program guidelines and acceptable standards of conduct.
 Report your departure date and reason to the RO/ARO in advance. You must depart the United States within 30 days of
completing or ceasing program activities. Overstaying the 30 days is a serious immigration violation that may negatively
affect your ability to obtain a new visa or re-enter the U.S. in the future.
 Home-Country Physical Presence Requirement: This requirement means that an Exchange Visitor who is within the
purview of section 212(e) of the Immigration and Nationality Act (substantially quoted in §62.44) must reside and be
physically present in the country of nationality or last legal permanent residence for an aggregate of at least two years
following departure from the United States before the exchange visitor is eligible to apply for an immigrant visa or permanent
residence, a nonimmigrant H visa as a temporary worker or trainee, or a nonimmigrant L visa as an intra-company transfer-
ee, or a nonimmigrant H or L visa as the spouse or minor child of a person who is a temporary worker or trainee or an intra-
company transferee.
I have read and understood my responsibilities as an Exchange Visitor at Valencia College. I understand that failure to comply
with the above requirements will result in the termination of my DS-2019, my program at Valencia College and all employment
contracts. I also understand a termination of my DS-2019 may negatively affect my ability to obtain a new visa in the future.
I have read and agree to comply with the terms and conditions of my admission and those of any extensions of stay as specified
by federal regulations. I certify that all information provided on these forms refers specifically to me and is true and correct to the best
of my knowledge. I certify that I seek to enter or remain in the United States temporarily, at Valencia College, and solely for the
purpose of pursuing the activity or activities identified in item 4 of the DS-2019.
___________________________________ ____________________________________ __________________
Exchange Visitor’s Name Signature Date
Exchange Visitor Responsibility Form
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This form should be used for identifying and authorizing any individuals who will be submitting or picking up documents
on your behalf. Your signature below is required.
EXCHANGE VISITOR INFORMATION:
Visitor’s Name: _______________________________________________ VID Number (if applicable): __________________
Email Address: _______________________________________________ Phone Number: ___________________________
Address Line 1: ____________________________________________________________________________________________
Address Line 2: ____________________________________________________________________________________________
City: ________________________________ State/Province: ________________________ Country: _____________________
In accordance with Valencia College policies and procedures, as well as state and federal law (FS §228.093, §20 U.S.C.A.
1232g), I, ______________________________________ , freely and voluntarily consent to the release of information.
Period of time during which consent shall be valid: From: ____________________ To: ________________________
Purpose/Type of disclosure:
Pick up my DS-2019
Assist in processing my admission application packet
Copy of identification attached
Other: ______________________________________________________________
Disclosure information to be given to:
Name: ______________________________________________________ Phone Number 1: __________________________
Email Address: _______________________________________________ Phone Number 2: __________________________
Address Line 1: ____________________________________________________________________________________________
Address Line 2: ____________________________________________________________________________________________
City: ________________________________ State/Province: ________________________ Country: _____________________
Disclosure information to be given to:
Name: ______________________________________________________ Phone Number 1: __________________________
Email Address: _______________________________________________ Phone Number 2: __________________________
Address Line 1: ____________________________________________________________________________________________
Address Line 2: ____________________________________________________________________________________________
City: ________________________________
Exchange Visitor’s Signature: _____________________________________________ Date: __________________________
First Name Last Name
month / day / year month / day / year
Information Release Form
11
This form should be used for all Exchange Visitor designations. You will need to complete this form and bring it with you
when you meet with your RO or ARO in the United States. Please note that you will need your Valencia ID number before
you can purchase your insurance. The insurance coverage must be for the duration of your program. If you extend your
program, you must also extend your insurance coverage period. Coverage includes the following:
 At least $50,000 person per accident/illness
 $7,500 for repatriation coverage
 $10,000 for medical evacuation coverage
 A deductible not to exceed $500 per accident/illness
Applicant Information:
Family Name: ______________________________________ First Name: ___________________ Middle Name: ___________
Valencia Identification Number (VID): ___________________
Credit Card Payment Instructions:
If you are paying your insurance premium by credit card, please include the following:
Credit Card Company: _________________________________________________________________________________
Credit Card Number: __________________________________________________________________________________
Expiration Date: ______________________________________________________________________________________
Authorization Statement: I, ________________________________________________________, give authorization to Valencia
(card holder’s printed name)
College to process the health insurance premium payment to my credit card in the amount of $__________________
__________________________________________________ ____________________________________
Card Holder Signature Date
Wire Transfer Instructions:
Wire transfers must include the Exchange Visitor's name, program dates or term, Valencia Identification Number (VID) and the
following notation: These funds are to be used to pay for the required Injury and Sickness Insurance policy for this applicant.
There must be enough funds wired to cover all processing fees. This generally does not exceed $50.
Payment should be wired to: Fifth Third Bank
P.O. Box 630900
Cincinnatti, OH 45263
ABA#: 042000314
International U.S. dollar wire transfers to: SWIFT # FTBCUS3CC
Deposited to: Valencia College
Account Number: 7440801798
Injury and Sickness Insurance Form
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JEV Application Prof Spec Scholar 06 01 12 (Valencia College)

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