Foreign National Information Form Page 2
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2FOREIGN NATIONAL INFORMATION FORM (PAGE 2)
The Foreign National Information Form must be completed before you can receive any form of payment.
PLEASE LIST ANY VISA IMMIGRATION ACTIVITY IN LAST THREE CALENDAR YEARS AND ALL F, J, M OR Q VISAS SINCE 1/1/85:
Date of Entry
Date of Exit
Visa Immigration Status
J-1 Subtype
Primary Activity
Have You Taken Any
Treaty Benefits
____/____/____
____/____/_____
______________________
__________________
__________________
Yes
No
____/____/____
____/____/_____
______________________
__________________
__________________
Yes
No
____/____/____
____/____/_____
______________________
__________________
__________________
Yes
No
____/____/____
____/____/_____
______________________
__________________
__________________
Yes
No
____/____/____
____/____/_____
______________________
__________________
__________________
Yes
No
____/____/____
____/____/_____
______________________
__________________
__________________
Yes
No
____/____/____
____/____/_____
______________________
__________________
__________________
Yes
No
____/____/____
____/____/_____
______________________
__________________
__________________
Yes
No
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____/____/_____
______________________
__________________
__________________
Yes
No
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____/____/_____
______________________
__________________
__________________
Yes
No
____/____/____
____/____/_____
______________________
__________________
__________________
Yes
No
VISA IMMIGRATION STATUS:
U.S. Immigrant/Permanent Resident
F-1 Student
J-2 Spouse or child
J-1 Exchange Visitor
H-1 Temporary Employee
of Exchange Visitor
Other ______________________________________________________________________________________________________________
J-1 VISA SUBTYPE:
01 Student
05 Professor
12 Research Scholar
02 Short Term Scholar
Other _____________________________________________________________________
PRIMARY ACTIVITY:
01 Studying in a degree program
05 Observing
09 Decorating Special Skills
02 Studying in a non-degree program
06 Consulting
10 Clinical Activities
03 Teaching
07 Conducting Research
11 Temporary Employee
04 Lecturing
08 Training
12 Here with Spouse
99 Other, please specify _______________________________________________________________________________________________
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.
Signature: _________________________________________________Local Phone Number: ____________________ Date: _______________
HOW TO COMPLETE THE FOREIGN NATIONAL INFORMATION FORM:
15. Immigration Status: Check the type of immigration status
1. Name: List full name.
that you currently hold. If you check U.S.
2. Social Security Number: Enter US social security number
Immigrant/Permanent Resident, holder of a “green card,”
issued by the US Social Security Administration not your
you may proceed to the bottom of the form. Sign and date.
ID number. do not list numbers not assigned by the United
16. Immigration Status for J-1: Check the appropriate J-1
States Social Security, i.e. Canadian social security number.
subtype.
All employees must have a social security number in order
17. Actual Primary Activity: Check one activity.
to work. If none, enter your ITIN issued by the IRS.
18. Actual Entry Date into the United States: Must include
3. ID#: Enter your Employee/Student/Faculty Identification
month, day and year. Approximate if you don’t know.
Number.
19. State Date: Must include month, day, and year.
4. Ethnicity: Check the appropriate box. If none of those listed
Approximate if you don’t know.
apply, check “Other” and write in ethnicity.
20. End Date: Must include month, day, and year.
5. Local Street Address: List your local US address.
Approximate if you don’t know.
6. Residence: List your non US address.
21. Occupation: Describe in general the service you will
7. Country of Citizenship(s).
perform.
8. Country that Issued Passport: List country for which you
22. Check the appropriate box.
were issued your passport. Not the country where it was
23. Is you spouse in the USA? Check the appropriate box.
issued.
Give number of other dependents in the USA.
9. Passport #: Enter your passport number.
24. Consultants/Self-employed Individuals: Check the
10. Visa #: Enter you visa number.
appropriate box. This includes any office at any location
11. Passport Expire Date: Date passport will expire.
specifically identified with you.
12. Visa Issue Date: Date visa was issued.
25. Tax residence is where you last paid taxes as a resident and
13. Visa Expire Date: Date visa will expire.
can be different from legal residence. Do not include the
14. Immigration Status: Check yes or no. If yes, complete the
USA.
above form for the time(s) you were present in the United
States. Approximate if you don’t know exact dates.
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