Page 1 of 2 Updated 9-4-06
XCHANGE VISITOR PROFILE
(DS-2019 Request Form B)
The Exchange Visitor must complete this form and return it to the FGCU department sponsor.
Please type or print clearly.
Exchange Visitor’s Family Name First Name
Date of Birth Place of Birth
(mm/dd/yy) City Country
Country of Citizenship _______ ___ Country of Legal Residence
resent position, e.g., Teacher/Professor/Lecturer/Research Scholar/Specialist (circle one). Other
Institution/location of present position
efore you begin this FGCU program will you have been in the U.S within the past 12 months as a J-1 student, professor,
research scholar, or J-2 dependent? No Yes
If “yes,” what category (student, researcher, scholar)
If your dependents will come to the U.S during your program, you must provide evidence of sufficient financial support
prior to the issuance of their DS-2019. List below dependents (spouse and children under 21).
Please indicate who will accompany you or will join you later (if “will join later,” please include start and end dates):
me to U.S.
Yes or No
Will join later.
start and end
.S. government regulations require that you and your dependents, who come during your program, be
covered by medical and accident insurance meeting specific requirements for the duration of stay in the U.S.
If you or your dependents are not already covered at the time of arrival, you must purchase coverage upon
arrival. All exchange visitors will be provided information on medical insurance requirements and insurance
programs available to them.
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