Office of International Affairs
Phone: (337) 482-6819 // Fax: (337) 262-1346
E-mail: exchange@
louisiana.edu // Web:
http://louisiana.edu/oia
J-1 APPLICATION
REQUEST FOR A DS-2019 FORM
Instructions:
Please complete all sections of the J-1 application. This application will need to be completed by both the
prospective exchange visitor as well as the UL Lafayette faculty or staff hosting the exchange visitor. Once the
application is complete, please forward the application to exchange@louisiana.edu. The following documents
should also be sent along with the completed application:
1. Copy of the standard UL Lafayette employment offer letter or, if no employment is involved, the UL Lafayette
letter of invitation.
2. Copy of the document(s) verifying the source and amount of funding which is in lieu of or in addition to UL
Lafayette funding.
3. Copy of the prospective exchange visitors resume or vita, if available.
4. Copy of the prospective exchange visitors passport.
1. Name::
Family Name First Name Middle Name
2. Gender: Male Female 3. Date of Birth:
Month Day Year
4. City and country of birth:
5. Country of Citizenship:
6. Country of legal permanent residence:
7. Present or former position in country of permanent residence:
8. Proposed dates of stay: From: To:
Month Day Year Month Day Year
9. Host department and phone number:
10. Title of proposed position:
11. Brief description of responsibilities:
12. Source and amount of funding:
University of Louisiana at Lafayette $
- OR -
Other (please specify): $
13. If applicable, please list all locations and dates of previous times in J-1 exchange visitor status:
14. Will the exchange visitor be accompanied by spouse or children? Yes No
If yes, give names, dates of birth, and places of birth on page 2.
Page 1
Office of International Affairs
Phone: (337) 482-6819 // Fax: (337) 262-1346
E-mail: exchange@louisiana.edu // Web: http://louisiana.edu/oia
DEPENDENT INFORMATION
1. Name:
Family Name First Name Middle Name
2. Gender : Male Female 3. Date of Birth:
Month Day Year
3. City and Country of Birth:
4. Citizen of: 5. Legal Permanent Resident of:
5. Relationship to Exchange Visitor: Spouse Child
DEPENDENT INFORMATION
1. Name:
Family Name First Name Middle Name
2. Gender : Male Female 3. Date of Birth:
Month Day Year
3. City and Country of Birth:
4. Citizen of: 5. Legal Permanent Resident of:
5. Relationship to Exchange Visitor: Spouse Child
DEPENDENT INFORMATION
1. Name:
Family Name First Name Middle Name
2. Gender : Male Female 3. Date of Birth:
Month Day Year
3. City and Country of Birth:
4. Citizen of: 5. Legal Permanent Resident of:
5. Relationship to Exchange Visitor: Spouse Child
Page 2
Office of International Affairs
Phone: (337) 482-6819 // Fax: (337) 262-1346
E-mail: exchange@louisiana.edu // Web: http://louisiana.edu/oia
Exchange Visitor Contact Information
Address:
( Street)
City: Province/Territory:
Country: Postal Code:
Phone Number: Email:
Is the exchange visitor currently in the U.S.? Yes No
If YES, current immigration status (e.g., J-1, F-1, H-1B):
Please submit the following documents to the OIA along with the exchange visitors completed J-1 application
1. Copies of all immigration documents (DS-2019(s), I-20(s) or I-797(s)
2. Copy of most recent I-94
3. Copy of passport
UL Laf
ayette faculty or staff hosting the exchange visitor:
Name and Title:
Department:
Phone Number: Email:
Required Health Insurance
The current regulations governing the J-1 Exchange Visitor Program requires J-1 exchange visitors and any
dependents who accompany the J-1 exchange visitor to have medical insurance coverage. The prospective J-1
exchange visitor is required by the United States Department of State to have at least:
1. Medical benefits of at least $100,000 per accident or illness
2. Repatriation of remains in the amount of $25,000
3. Expenses associated with medical evacuation in the amount of $50,000
4. A deductible not to exceed $500 per accident or illness
On page 4 of this J-1 application packet, you will find a Certification of Medical Insurance form. This form
MUST be completed by the exchange visitor’s insurance agent as well as the prospective exchange visitor.
Page 3
Office of International Affairs
Phone: (337) 482-6819 // Fax: (337) 262-1346
E-mail: exchange@louisiana.edu // Web: http://louisiana.edu/oia
Certification of Medical Health Insurance Coverage
J-1 Exchange Visitor
Name:
Personal Email:
Expected Arrival Date: Expected Departure Date:
(Month/Day/Year) (Month/Day/Year)
I certify that the above named individual and dependents have medical benefits of at least
$100,000.00 per accident or illness, repatriation of remains in the amount of $25,000.00, expenses associated
with medical evacuation of the exchange visitor to his or her home country in the amount of $50,000.00 and a
deductible not to exceed $500.00 per accident or illness.
Dates of Coverage: From: To:
Name of Medical Health Insurance Company Signature of Agent Representing Date
Medical Health Insurance Company
Please attach the following documents:
Proof of the exchange visitors medical health insurance coverage (such as ID card or letter from insurance
company).
Verification of dates of coverage
A description, in English, of the conditions of the medical health insurance coverage.
If the medical health insurance is based on employee benefits provided to the exchange visitor’s parent,
documentation verifying the age through which the exchange visitor is eligible for coverage.
I certify that I have enrolled in the above medical health insurance program. I will continue to maintain this
coverage and will notify your office of any changes and provide appropriate documentation of any changes. I
will provide documentation of continuation of the required coverage upon request for extension of J-1 status.
By agreeing to and submitting this form, I acknowledge that the information provided about my medical health
insurance coverage is true and accurate and I understand that I must carry the requisite insurance for as long as I
am enrolled at the University of Louisiana at Lafayette. If this document contains any false, fraudulent or
misrepresented information, the University of Louisiana at Lafayette will have no responsibility (legal or
financial) to any health issues that apply to and have been incurred by me, including death. I acknowledge that I
am legally responsible for any and all medical expenses during my enrollment at the University of Louisiana at
Lafayette. Further, I understand that the Office of International Affairs along with Student Health Services
reserves the right to investigate the validity of private policy benefits in order to meet all listed requirements.
Signature of Exchange Visitor Date
Page 4
Office of International Affairs
Phone: (337) 482-6819 // Fax: (337) 262-1346
E-mail: exchange@louisiana.edu // Web: http://louisiana.edu/oia
Approval for the Employment/Visit of an Exchange Visitor (J-1 Status)
Name of Prospective Exchange Visitor:
Title of Position: Department:
We Certify that:
1. We agree to accept responsibility for this participant for the entire period of stay as requested on the
form DS-2019. We hereby certify that there is sufficient funding to support this individual for the entire
period stated on the J-1 visa application request form,
2. Should problems occur with the exchange visitor regarding employment, studies, etc., I (we) agree to
follow the appropriate standard university procedures in remedying said problems. These procedures
must be followed even when UL Lafayette does not provide financial support to the exchange visitor,
3. The prospective exchange visitor is proficient in English,
4. We agree to notify the Office of International Affairs immediately of any changes within the
department, which affects the status of an exchange visitor (i.e. loss of funding or significant change in
duties),
5. We agree to notify the Office of International Affairs immediately if the exchange visitor ceases to
participate in the exchange visitor Program prior to the end of his/her program date.
6. We agree to notify the Office of International Affairs at least 45 days in advance of the program
completion date to request an extension of the exchange visitor’s stay.
Name of Faculty/Staff Sponsor:
Signature: Date:
Approval is granted to employ or invite the prospective exchange visitor:
Date:
Department Chair
Date:
Dean
Date:
Vice President (Academic Affairs)
Date:
President
Page 5
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