Foreign National Data Form Page 2
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2PLEASE LIST ALL USA - F, J, M, Q OR H VISA IMMIGRATION ACTIVITY SINCE 1/1/1985
Date of Exit /
Visa
Have you taken any
Date of Entry
Change of Status
Immigration Status
J-1 Subtype
Primary Activity
tax treaty benefits?
Yes
No
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Yes
No
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Yes
No
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Yes
No
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Yes
No
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Yes
No
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Yes
No
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Yes
No
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PLEASE LIST ALL OTHER UNITED STATES VISA IMMIGRATION ACTIVITY IN LAST THREE (3) CALENDAR YEARS
Yes
No
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Yes
No
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Yes
No
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Yes
No
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Yes
No
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I hereby certify that all of the information on this form 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 Data Form to the Payroll Department.
Signature:
Date:
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Revised 8/9/13
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