Fillable University of Mississippi Medical Center H-1B Applicant Information Form

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University of Mississippi Medical Center H-1B Applicant Information Form

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The University of Mississippi Medical Center H-1B Applicant Information Form form is 2 pages long and contains:

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H-1B APPLICANT INFORMATION FORM
This form must be completed by the H-1B applicant. A copy of the applicant’s curriculum vitae/resume should be
returned with the completed form. Return this form together with the Request for H-1B Petition to the Office of
International Services. Please enter all dates in the MM/DD/YYYY format.
Name (First, Middle, Last):
Current Address:
Email Address:
Province of Birth:
Date of Birth:
Country of Birth:
Social Security Number (if applicable):
Country of Citizenship:
Current Occupation:
Highest level of education obtained and major field o
f study:
If you are currently in the U.S., please answer the following:
Current nonimmigrant status (F-1, H-1B, etc.):
Date of last arrival:
Form I-94 #:
Passport #:
Date current status expires:
Passport Issue Date:
I am requesting a “change to” or “extension of” H-1B status, to be effective on:
I will apply for an H-1B visa at the U.S. consulate in (City and Country):
Passport Expiration Date:
Petition receipt number from Form I-797 Notice of Action (if applicable):
Date that you will terminate employment with your current employer:
Please check one of the following:
Please provide a summary of your prior employment history including title(s), date(s) of employment and job duties.
Attach a separate page to this form if necessary:
Phone Number:
If you will be accompanied by dependents, please answer the following:
Dependent’s Name
Relationship
Nonimmigrant Status
Expiration Date
Have you ever been involved in removal proceedings?
Yes No
Have you ever been denied an H-1B classification? Yes No
Has an immigrant petition (Form I-140) and/or application for permanent residence (Form I-485) ever been fi
led on your
behalf? Yes No
Within the past 6 years, have you:
•
worked in H-1B status at a college, university, or nonprofit/governmental institution?
Yes No
•
worked in H-1B status at a corporation or other “for profit” entity? Yes No
left the United States for more than one year after attaining H-1B status?
Ye
s
No
If you indicated (above) the you were in a "J" nonimmigrant classification and you were subject to the
two-year home residence requirement, please check the appropriate answer:
I returned to my home country for 2 years and fulfilled the home residency requirement.
I certify to the best of my knowledge that the information provided on this form is correct and request that
the University of Mississippi Medical Center submit an H-1B petition on my behalf.
___________________________________________
Signature Date
Will any of the dependents listed above require a change to or extension of H-4 status? Yes No
Please give your immigration history and nonimmigrant status (F-1, J-1, H-1, etc.) for the past seven years.
Do not include any periods of stay in B-1/B-2 visitor status.
If yes, please provide details:
•
Name of Employer/Sponsor Nonimmigrant Status Dates of Employment (from/to)
I obtained a waiver of the 2-year home residency requirement
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University of Mississippi Medical Center H-1B Applicant Information Form

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Completed 10 April 2020

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