Page 1 of 2 Updated 9-4-06
E
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.
Male Female
______
Exchange Visitor’s Family Name First Name
Middle Name
Date of Birth Place of Birth
_______
(mm/dd/yy) City Country
Country of Citizenship _______ ___ Country of Legal Residence
_____________________
P
resent position, e.g., Teacher/Professor/Lecturer/Research Scholar/Specialist (circle one). Other
______________
Institution/location of present position
B
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)
Dependent Data
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):
Relationship
(spouse/child)
(mm/dd/yy)
F
amily Name
Gi
ven Name
B
irthdate
(mm/dd/yy)
Bi
rthplace
Country of
Citizenship and
Legal Residence
Come with
me to U.S.
Yes or No
Will join later.
Provide
start and end
dates
U
.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.
INTERNATIONAL SERVICES
Connect with the World
Page 2 of 2
I
certify that the information provided is true and accurate to the best of my knowledge.
An original signature of the visitor is not required. An FGCU department sponsor may sign to verify accuracy of information.
_____________
____________________________________ _____________
Signature of Exchange Visitor Date
OR
_____________
____________________________________ _____________
Signature of FGCU Department Sponsor Date
M
ailing Address of Exchange Visitor (Abroad)
_____________________________________________________
Phone: _____________________ ______________________________________________________
Fax: ________________________ ______________________________________________________
Email: __________________________________________________
Please use the space below to provide additional information corresponding to any previous questions on this form.
click to sign
signature
click to edit
click to sign
signature
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