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JEVApplicationStudent 2011-2012 03-19-122 JEV Application Student_2011-2012_03-19-12

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Updated: 06/06/2011
J Exchange Visitor PROGRAM
APPLICATION PACKET
STUDENT DESIGNATION
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
Transfer In Clearance Form 11
Injury & Sickness Insurance Form 12
ORLANDO, FLORIDA, U.S.A.
2
Steps to Register
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 type.
_____ Step 2: 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 3: Complete Valencia’s online admissions application and pay the college application fee at:
www.valenciacollege.edu/admissions. Select “Non-Degree Seeking J Exchange Visa Only.”
_____ Step 4: Complete the F/J Exchange Visitor (JEV) Program Application Packet:
_____ Step 5: Submit this JEV Application to the Responsible Officer or Alternative Responsible Officer listed on the next page.
If you would like your 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.
EXCHANGE STUDENTS: Submit your application and a copy of your Learning Agreement (list of authorized
courses from your home institution) to the Study Abroad and Global Experiences office 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.
Be notified of your admission/acceptance by email.
Be allowed to create a Valencia Atlas account. You should create your Atlas account (3 to 5 business days after
submitting your application) at: http://atlas.valenciacollege.edu/.
Receive a Valencia Identification Number (VID) by email.
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 U.S. 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: Every program sponsor (the individual or entity funding your program) must
complete this form. Print out one for each sponsor.
J Exchange Visitor Responsibility Form: Read and sign this form.
Information Release Form (if applicable): Complete and sign this form if there is someone in the U.S. assisting
you in this process who will be submitting or picking up documents on your behalf, or if they will be representing your
intentions with the College.
Transfer-In Clearance Form: This is for students transferring from other U.S. institutions. The school A/RO should
complete the form.
Injury and Sickness Insurance Payment Options Form: Follow the instructions on the top of the form.
Include a clear, readable copy or scanned image of the photo page and issue/expiration page of your passport.
Submit proof of English language proficiency (TOEFL test scores for degree-seeking students; confirmation letter
written by applicant and signed by home institution for non-degree seeking students).
Pay the application fee and the program deposit (if applicable).
Application Checklist
3
Steps to Register (continued):
_____ 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.
_____ 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/Consulate in your home country to apply for the J-1 visa.
_____ Step 10: After your visa request has been approved, make your transportation and housing arrangements for your stay in
Orlando.
Upon arrival to the United States (you must arrive at least 2 weeks, but no more than 30 days, prior to your start date):
Check in with the College’s Responsible Officer.
Pay for your Injury and Sickness Insurance at the campus Business Office.
Take any required assessments (if applicable).
Attend the mandatory New Student Orientation.
Register for your classes online through Atlas using the Student Services
Tab. NOTE: Exchange Students will use the Out-of-State Tuition Waiver.
Course enrollment is on a space available basis only. You should have
second and third options in case you do not get the classes that you want.
Exchange Students will need to get an updated Learning Agreement signed
if their course selection changed.
Purchase your course textbooks at the College Bookstore.
Request your parking decal through your Atlas account.
Get your Student ID (bring your paid receipt of classes and passport).
Attend the mandatory J Exchange Visitor Orientation.
Begin classes.
Application Checklist
Valencia College Contacts
STUDENTS:
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
PROFESSORS & SCHOLARS:
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
4
Today's Date (mm/dd/yyyy): _________________________________
Designation Type: Application Type: Valencia Home Campus Request:
Student Degree-Seeking First-Time Participant West Winter Park
Student Non-Degree Seeking Transfer In (U.S. schools) East Osceola
Exchange Program
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.
_____________________________ __________________________ __________________________
Participant'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 estimated 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 program type,
duration, the projected expenses, and the total into the table below. Do not include expenses that you will not incur.
Exchange Students can enroll for up to 18 credits in one semester and receive a tuition waiver.
*Tuition waiver granted based on Memorandum of Understanding between Valencia and the home institution.
**Prices are subject to change. Insurance coverage for a spouse for one year is $4,060 and each child is $1,660.
***Additional dependents will require certification of additional funds in the amount of $2,250 per semester, per person.
Financial Support in U.S. Dollars:
If you are not participating in an Exchange Program, it is important to note that the majority of funds to pay for your tuition,
books, and insurance (at least 50%) must come from a sponsoring agency in order to qualify for the J visa. 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 Semester
(15 credits)
1 Year
(30 credits)
Application Fee (nonrefundable)
$ 35 $ 35
Tuition and Fees: 1 credit hour = $375.22; full-
time enrollment is 12 to 18 credits*
$ 5,628 $ 11,257
Books
$ 589 $ 1,178
Injury and Sickness Insurance**
$ 453 $ 1,157
Living Expenses (lodging, utilities, food, bus
transportation, etc.)***
$ 5,180 $ 15,541
Social and Cultural Activities
$ 800 $ 1,600
Total Financial Requirement: $ 12,685
$ 30,768
Exchange Visitor
Dependents
$ 0.00
$ 0.00
0.00
7
TO BE COMPLETED BY STUDENT’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 (living expenses) 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/leasing agreement or rent receipt.
Included is a copy of my deed of ownership or my most recent residence tax bill.
I swear that the information I have provided above is true and correct:
___________________________________________________
Signature of Leasee/Landlord/Property Owner/Host
___________________________________________________
Sworn and suscribed before me this day
___________________________________________________
Signature of Notary
Affidavit of Living Expenses
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9
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 or Alternate 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 validated 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 required insurance policy provided through the College 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. You 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 RO/ARO.
 Obtain a travel signature on the DS-2019 from the RO/ARO prior to departing the United States throughout your program
duration. Please note that you may not be allowed to re-enter the U.S. without the required travel authorization.
 Comply with all academic program guidelines and acceptable standards of conduct as detailed in the College catalog.
 Report your departure date and reason to the RO/ARO in advance. You must depart the United States within 30 days of
completing your program. 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.
 If you end your program before the official end date, you must depart the United States immediately.
 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 all eligible dependents, 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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10
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:
Student’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
Disclose my test results
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: __________________________
Third Party’s Signature: _____________________________________________ Date: __________________________
(to be signed upon release of the DS-2019)
First Name Last Name
month / day / year month / day / year
Information Release Form
V0
11
If you are currently enrolled in or recently graduated from a college, university, high school, or language institute as an F-1
student or J-1 Exchange Visitor, you must complete this form. If you will be traveling outside of the U.S. before starting
your program at Valencia, please contact your program department isted on page 4 of this packet to arrange delivery.
Applicant Information:
Current Visa Type: F-1 J-1 Program Start Date: ___________________________________
Family Name: ______________________________________ First Name: ___________________ Middle Name: ___________
Date of Birth (MM/DD/YYYY): __________________________ Gender: Male Female
I-94#: _______________________ SEVIS#: _______________________ DS-2019 #: _______________________
Required Original Documents:
All previously issued immigration documents must be presented in their original or scanned form to the RO/ARO:
I-20s DS-2019s Visas I-94 Passport I-797 Notices of Action
Current School Information:
Please have the institution's immigration advisor complete the following information and sign the form. You can bring this
form in person, scan and email, fax, or mail to the designated contact listed in this application packet.
1. Indicate dates Exchange Visitor was in J-1 Status: From (month/year): _______ /_______ To (month/year): _______/________
2. Has this student maintained their non-immigrant status throughout the duration of their program? Yes No
If no, please explain: __________________________________________________________________________________
3. Has this student experienced financial difficulties? Yes No
If yes, please explain: __________________________________________________________________________________
4. Has this student been granted practical or academic training (internship)? Yes No
If yes, please describe type and dates of participation: ________________________________________________________
5. Do you operate on semester of quarter hours? Semester Quarter Other: _________________
6. Please indicate the number of credit hours your institution considers as full time for each term of your academic calendar:
Fall_____ Winter_____ Spring_____ Summer_____
7. What is the anticipated date of release in SEVIS? ___________________________
8. Additional comments:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
DSO/ARO Complete Name: ____________________________________ Title: ___________________________________
Institution: ___________________________________________________ Phone: _________________________________
Email Address: _______________________________________________
Signature: ___________________________________________________ Date: ___________________________________
Transfer-In Clearance Form
12
This form should be used for all Exchange Visitor designations. You will need to complete this form and fax it to the
corresponding contact as listed on page 4 of this packet or bring it with you when you meet with your RO/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
V0
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