Foreign National Information Form
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1
2FOREIGN NATIONAL INFORMATION FORM (PAGE 1)
The Foreign National Information Form must be completed before you can receive any form of payment.
All applicable questions below must be answered. A copy of both sides of your I-94 Form “Arrival and Departure Record” (a small white card inside your passport), copy of your U.S. VISA
from your passport, and I-20 or DS-2019 must be attached to this form. This form must be returned before any check can be issued by the Financial Affairs Department and must also be
completed by anyone receiving remission/scholarship.
Last or Family Name: ____________________________________First: _____________________________ Middle: ________________________
Social Security # ____________________________ USM ID # ____________________________ Date of Birth ___________________________
Ethnicity
White
Black
Hispanic
Asian
Other __________________________
U.S. LOCAL STREET ADDRESS:_____________________________
FOREIGN RESIDENCE ADDRESS: ________________________
__________________________________________________________
________________________________________________________
Address Line 2: ___________________________________________
Address Line 2: _________________________________________
Address Line 3: ___________________________________________
Address Line 3/City: ____________________________________
City: _____________________________________________________
Postal Code: ___________Providence/Region: ______________
State: ___________________________Zip: ____________________
Foreign Country: ________________________________________
Country of Citizenship: ___________________________________
Country That Issued Passport: _____________________________
Passport #: ______________________________________________
Visa #: __________________________________________________
(red number)
Passport Expire Date: _________________________Visa Issue Date: ________________________Visa Expire Date: ______________________
Have you ever had another immigration status in the United States?
Yes
No
If yes, see page 2.
IMMIGRATION STATUS:
U.S Immigrant/Permanent Resident
F-1 Student
J-2 Spouse or Child of
J-1 Exchange Visitor
H-1 Temporary Employee
Exchange Visitor
Other: __________________________________________________________________________________________________________
IF IMMIGRATION STATUS IS J-1, WHAT IS THE SUBTYPE? CHECK ONE:
01 Student
05 Professor
12 Research Scholar
02 Short Term Scholar
Other: _____________________________________________________________
WHAT IS THE ACTUAL PRIMARY ACTIVITY OF THE VISIT? CHECK ONE:
01 Studying in a Degree Program
05 Observing
09 Demonstrating Special Skill
02 Studying in a Non-Degree Program
06 Consulting
10 Clinical Activities
03 Teaching
07 Conducting Research
11 Temporary Employment
04 Lecturing
08 Training
12 Here with Spouse
WHAT IS THE ACTUAL DATE YOU
WHAT IS THE START DATE OF
WHAT IS THE PROJECTED END
ENTERED THE UNITED STATES?
YOUR IMMIGRATION STATUS
DATE OF YOUR IMMIGRATION
FOR THIS PRIMARY ACTIVITY?
STATUS PRIMARY ACTIVITY?
______/______/______
______/______/______
______/______/______
Month
Day
Year
Month
Day
Year
Month
Day
Year
INCOME PROVIDING ACTIVITY
WHAT TYPE OF STUDENT?
SPOUSE IN U.S.A.?
(e.g. Professor, Student Worker, etc.)
Undergraduate
Masters
Yes
No
__________________________
Doctoral
Other _________
Number of dependents:
FOR CONSULTANTS/SELF EMPLOYED INDIVIDUALS:
COUNTRY OF TAX RESIDENCE IF DIFFERENT FROM
Do you/will you have an office (fixed base) in the USA?
FOREIGN RESIDENCE ADDRESS:
Yes
No If yes, how many days in this tax year did you/
Did tax residency end?
Yes
No
will you have this office (fixed base)? __________ Days
If yes, when ______/______/______ (Month/Day/Year)
I hereby certify that all of the above information is true and correct. I understand that if my status changes from that which I have indicated
on this form, I must submit a new Foreign National Information Form to the International Student Affairs office.
According to the Privacy Act for Collection of SSNs: We are required to inform you that The University of Southern Mississippi is requesting
your Social Security Number (SSN) to be used for Federal and State reporting, as mandated by Federal and State law.
Signature: _________________________________________________Local Phone Number: ____________________ Date: _______________
Email Address: ________________________________________________________________
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