Foreign National Information Form - Us Department Of Homeland Security 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 I-20 or IAP66 must be attached to this form. This form just 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) ID #: __________________________________________________________

(4) U.S. LOCAL STREET ADDRESS: ________________________

(5) FOREIGN RESIDENCE ADDRESS:

________________________________________________________

(4) Address Line 2:_________________________________________

(5) Address Line 2:_________________________________________

(4) Address Line 3:_________________________________________

(5) Address Line 3/City_____________________________________

(4) City: _________________________________________________

(5) Postal Code: _____________Province/Region: _______________

(4) State: ______________________________ Zip: ______________

(5) Foreign Country: _______________________________________

(6) Country of Citizenship: ______________________________________ (7) Country That Issued Passport: ____________________________________

(8) Passport #: ________________________________________________ (9) Visa #: _______________________________________________________

(10) Have you ever had another immigration status in the United States? (

)Yes. (

) No. If yes, see page 2.

(11) 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: _________________________________________________________________________________________________________________________

(12) IF IMMIGRATION STATUS IS J-1, WHAT IS THE SUBTYPE? CHECK ONE:

01 Student

05 Professor

12 Research Scholar

02 Short Term Scholar

Other: _____________________________________________________________________

(13) 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

(14) WHAT IS THE ACTUAL DATE YOU

(15) WHAT IS THE START DATE OF YOUR

(16) WHAT IS THE PROJECTED END DATE

ENTERED THE UNITED STATES?:

IMMIGRATION STATUS FOR THIS

OF YOUR IMMIGRATION STATUS

PRIMARY ACTIVITY?:

________/__________/___________

Month

Day

Year

Month

Day

Year

Month

Day

Year

(17) INCOME PROVIDING ACTIVITY

(18) WHAT TYPE STUDENT?:

(19) SPOUSE IN USA?:

(e.g. PROFESSOR OF CHEMISTRY)?:

Undergraduate

Masters

Yes

Number of dependents _____________

Doctoral

Other ______________

_______________________________________

(20) FOR CONSULTANTS/SELF EMPLOYED INDIVIDUALS:

(21) COUNTRY OF TAX RESIDENCE IF DIFFERENT FROM FOREIGN

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

RESIDENCE ADDRESS:

Yes

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

Did tax residency end?

Yes

No If yes, when _____/_____/_____

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 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: __________________