Fillable WCU International Programs & Services: J-1 Visa Document (Western Carolina University)

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WCU International Programs & Services: J-1 Visa Document (Western Carolina University)

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WCU International Programs & Services: J-1 Visa Document for Visiting Scholar
The purpose of the J-1 exchange visitor visa for professors, research scholars, and short-term scholars is to facilitate international
collaborative teaching and/or research efforts. Visitors (who must typically have training at the master’s level or higher) are invited
to the U.S. for a program with a specific objective and length of stay from a minimum of three weeks to a maximum of five years. All
J-1 exchange visitors at WCU are required to have at least a master’s degree in a related field and have demonstrated relevant
experience in their field of expertise.
To ensure that your visitors will be able to arrive on schedule, this form should be completed three months prior to the anticipated
date of arrival to allow adequate time for processing and obtaining visas.
PART 1. Visiting professor / research scholar information ( to be completed by visitor
)
Last Name: _______________________________________ First Name: _______________________________________
Middle Initial: _____________________________________ Male: _____________ Female: ____________
Date of Birth (MM/DD/YYYY): (____/____/________) City of Birth: ______________________________________
Country of Birth: __________________________________ Country of legal permanent residents (if other than
Country of Citizenship: ___________________________ country of citizenship): ____________________________
Visitor’s job title and name of institutional in home Are immediate family members accompanying your
country: ___________________________________________ visior (spouse and/or children): Yes ______ No _______
Please identify visitor’s primary activity at WCU: Teaching _________________ Research _________________
Other (please specify) ____________________________________________________________________________________
Period of visitor’s program at WCU (MM/DD/YYYY): From: ____________________ To: ____________________
Brief description of your primary program activity at WCU (e.g. research in quantum theory):
Visitor’s Primary work location at WCU (e.g. College of Business): _______________________________________
List any previous time in the U.S. in J-1 or J-2 status in the past three years: From:_______________ To: _______________ Status: __________
Please Provide visitor’s address for mailing purpose:
Phone Number: __________________________________ Email: ___________________________________
1
WCU International Programs & Services: J-1 Visa Document for Visiting Scholar
Part 2. Complete only if visitor is already in the U.S. ( to be completed by visitor
)
(Attach copy of visitor’s I-94card and, if in J-1 status, any previous DS-2019 forms)
Current visa status: _____________________________________ Date of entry to the U.S. ________________________________
Part 3. Funding sources ( to be completed by visitor
)
A minimum of $15,000/year for visitor, $8,000/year for spouse (or first dependent), and $5,500/year for each child must be
documented. List amount and source(s) of funding.
WCU Salary or stipend (if applicable): ____________________
Is funding availability certain for the amount of time requested? Yes: __________ No: __________
Other funding: ____________________________________________ Funding sources: _____________________________________________
Part 4. Processing information ( to be completed by the hosting department
)
How shall we forward the J-1 DS-2019 after it is ready? ( please select one )
Call department for pickup: Department phone: _____________________________________________
Campus mail to department : Campus address: ______________________________________________
______________________________________________
______________________________________________
FedEx / UPS using your account #: ____________________________________________________________
Part 5. Information needed to ensure compliance with J-1 regulations ( to be completed by hosting department
)
J-1 visitors may not be appointed to technician positions and may not be a candidate for tenure.
If your visitor will receive WCU funds, indicate how the funds will be distributed:
Honorarium: _________________________ Reimbursement of expenses: ___________________
Salary: ________________________________ Other: ___________________________________________
All J-1 exchange visitors and their J-2 dependents are required to have medical insurance. If no other insurance is available, the
visitor must enroll in WCU’s mandatory health insurance program for international students and scholars. The 2014-2015 rate is
$87.60 per month. Dependent insurance costs are higher.
2
WCU International Programs & Services: J-1 Visa Document for Visiting Scholar
Please indicate your understanding of how requirements will be met. ( please only select one )
WCU employee healh insurense benefits, paid by the Department: Yes __________ No __________
Department will purchase insurance benefits through international students and scholars plan:
for visitors only: __________ for visitors and dependents: __________
Visitor is responsible for all insurance costs: __________
Other (please explain): ____________________________________________
Part 6. Required documents
Please submit the following documents with this form to the Office of International Programs and Services, Camp 109 (to be sent
by the department)
A. Original letter of invitation to your visitor outlining program objectives and period of duration. Please see J-1 Guidelines
for sample Appendix A.
B. Copy of visitor’s CV
C. Copy of completed Form “Request for J-1 Visa Document.”
D. Documentation of funding from funding source
E. Copy of visa documentation if visitor is already in the U.S. (See Part 2).
Part 7. Responsibilities of host unit
By signing this form, you, as a representative of the host unit, agree to do the following:
A. I understand federal law restricts the sharing of certain technologies and software with foreign nationals. These rules are
complex and substantial penalties may be imposed for violations. If the visitor may have access to export controlled
technology or software controlled by federal law, the hiring unit should contact the Office of University Counsel to
ensure that all applicable requirements are met
B. I understand that I am to have the J-1 visitor report to the Office of International Programs and Services for check-in and
orientation within one week of arrival.
C. I understand that I am to encourage your visitor to participate in the academic and social activities of my unit as well as in
cross cultural activities on the campus and within the community.
D. I understand that I am to notify International Programs and Services when my visitor completes his/her program, if there
is a significant change in the program, or if termination of the visitor’s program become necessary.
3
WCU International Programs & Services: J-1 Visa Document for Visiting Scholar
Part. 8 Signatures
This is to verify that the information contained in this form is correct to the best of my knowledge and that I agree to the
responsibilities outlined in Part 7. I also certify that the purpose of this exchange visitor’s program is to stimulate international
collaborative teaching and/or research efforts and that funding is guaranteed for the period of time requested.
Name and Title of Host professor: _______________________________ Name of Academic Department: ____________________________________
Email: _____________________________________________________________ Phone: _______________________________________________________________
Campus address: _________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Signature: ________________________________________________________ Date ( MM/DD/YYYY ): ____________________________________________
Name of College / School Dean: _________________________________ Signature: ___________________________________________________________
Date ( MM/DD/YYYY ): __________________________________________
Provost Signature: _______________________________________________ Date ( MM/DD/YYYY): _____________________________________________
Part 9. Dependent information form
Complete this page for all dependents accompanying your visitor to the U.S. Please notice that only spouse and children (under
21) are considered dependent for the purpose of visa processing.
Family Name: ___________________________________________________ Given Name: ________________________________________________________
Middle Name: ___________________________________________________
Date of Birth ( MM/DD/YYYY ): ________________________________ City of birth: ________________________________________________________
Country of birth: ________________________________________________ Country of legal permanent residence: ____________________________
Country of citizenship: __________________________________________ Relationship to visitor: ______________________________________________
------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Family Name: ___________________________________________________ Given Name: ________________________________________________________
Middle Name: ___________________________________________________
Date of Birth ( MM/DD/YYYY ): ________________________________ City of birth: ________________________________________________________
Country of birth: ________________________________________________ Country of legal permanent residence: ____________________________
Country of citizenship: __________________________________________ Relationship to visitor: ______________________________________________
------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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WCU International Programs & Services: J-1 Visa Document for Visiting Scholar
Family Name: ___________________________________________________ Given Name: ________________________________________________________
Middle Name: ___________________________________________________
Date of Birth ( MM/DD/YYYY ): ________________________________ City of birth: ________________________________________________________
Country of birth: ________________________________________________ Country of legal permanent residence: ____________________________
Country of citizenship: __________________________________________ Relationship to visitor: ______________________________________________
------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Family Name: ___________________________________________________ Given Name: ________________________________________________________
Middle Name: ___________________________________________________
Date of Birth ( MM/DD/YYYY ): ________________________________ City of birth: ________________________________________________________
Country of birth: ________________________________________________ Country of legal permanent residence: ____________________________
Country of citizenship: __________________________________________ Relationship to visitor: ______________________________________________
------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Family Name: ___________________________________________________ Given Name: ________________________________________________________
Middle Name: ___________________________________________________
Date of Birth ( MM/DD/YYYY ): ________________________________ City of birth: ________________________________________________________
Country of birth: ________________________________________________ Country of legal permanent residence: ____________________________
Country of citizenship: __________________________________________ Relationship to visitor: ______________________________________________
------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Family Name: ___________________________________________________ Given Name: ________________________________________________________
Middle Name: ___________________________________________________
Date of Birth ( MM/DD/YYYY ): ________________________________ City of birth: ________________________________________________________
Country of birth: ________________________________________________ Country of legal permanent residence: ____________________________
Country of citizenship: __________________________________________ Relationship to visitor: ______________________________________________
------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Family Name: ___________________________________________________ Given Name: ________________________________________________________
Middle Name: ___________________________________________________
Date of Birth ( MM/DD/YYYY ): ________________________________ City of birth: ________________________________________________________
Country of birth: ________________________________________________ Country of legal permanent residence: ____________________________
Country of citizenship: __________________________________________ Relationship to visitor: ______________________________________________
5
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WCU International Programs & Services: J-1 Visa Document (Western Carolina University)

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Completed 1 September 2020

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