Foreign National Information Form printable pdf download

FOREIGN 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 1-20 or DS-2019 must be attached to this form. This form must be returned before any check can be issued by the

Payroll or Accounts Payable Department and must also be completed by anyone receiving tuition remission/scholarship.

(1)

Last or Family Name: _________________________________________ First _______________________________ Middle __________________

(2)

Social Security #: _________________________________________________

(3) U.S. Local Street Address: __________________________

(4)

Foreign Residence Address: ___________________________________

.___________________________________________________

._______________________________________________________________

Address Line 2: ____________________________________

Address Line 2: __________________________________________________

Address Line 3: ____________________________________

Address Line 3/City: ______________________________________________

City: ____________________________________________

Postal Code: ___________________ Province/Region: __________________

State:

Zip:

Foreign Country:

(5) Country of Citizenship: _____________________________________ (6) Country That Issued Passport: ____________________________________

(7) Passport # _________________________________________________ (8) VISA # _____________________________________________________

(Not the control number that begins with a year)

(9) Have you ever had another immigration status in the United States? ____ Yes ____ No If yes, see page 2.

(10) Immigration Status:

U.S. Immigrant/Permanent Resident

F-1 Student

J-2 Spouse or Child of Exchange Visitor

J-1 Exchange Visitor

H-1 Temporary Employee

Other: ___________________________________________________________________________________________________________

(11) If Immigration Status is J-1, What is the Subtype? Check One:

01 Student

05 Professor

12 Research Scholar

02 Short Term Scholar

Other: ______________________________________________________________

(12) What is the actual primary activity of the visit? Check One:

01 Studying in a Degree Program

05 Observing

09 Demonstrating Special Skills

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

(13) What is the actual date you entered

(14) What is the start date of your immigration

(15) What is the projected end date of

The United States?:

Status for this primary activity?:

your immigration status primary activity?:

______/ _______/ ________

_______/ ________/ __________

_______/ _______/ ________

Month Day

Year

Month

Day

Year

Month

Day

Year

(16) Income providing activity (e.g.

(17) What type student?:

(18) Spouse in USA?:

Professor of Chemistry)?:

Undergraduate

Masters

Yes

Number of Dependents ___________

Doctoral

Other

(19) For Consultants/Self Employed Individuals:

(20) Country of tax residence if different from Foreign Residence

Do you/will you have an office (fixed base) in the USA?

address: Did tax residency end?

Yes

No If yes, how many days in this tax year did you/will

If yes, when? _______/_______/_________

you have office (fixed base)? _____________

Month

Day

Year

Days

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 Payroll Department.

Signature: ________________________________________________ Local Phone Number: _________________________ Date: __________________