Ds 2019 Form - Application For A Certificate Of Eligibility

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International Student & Scholar Institute (ISSI)
Application for a Certificate of Eligibility (I-20 or DS-2019)
School of Professional & Continuing Studies (SPCS) – Academic Year 2006/2007
Mail to: School of Professional & Continuing Studies (SPCS), Northeastern University
360 Huntington Avenue, 270 Ryder Hall, Boston, MA 02115
Complete the enclosed form and send it, along with other required documents (listed in Section V) directly to the School of Professional
& Continuing Studies (SPCS) at the address above. After receiving all of the required documents from SPCS, the International Student
& Scholar Institute (ISSI) will need a minimum of two weeks to issue a university sponsored F-1 or J-1 visa eligibility document (I-20
or DS-2019). The I-20 or DS-2019 is required to apply for a student visa (F-1 or J-1) at a U.S. Consulate. If you are already in the U.S.,
the Certificate of Eligibility is also required to support a change of nonimmigrant status application or to initiate a transfer of F-1/J-1
immigration status/SEVIS record from your current school to Northeastern University.
I – PERSONAL INFORMATION
. (Please refer to the itemized instructions on the DCF Form
– PRINT CLEARLY AND LEGIBLY
Instruction Sheet: ISSI Form 659, which can be obtained online at
if needed.)
1. Gender
Male
Female
2. Marital Status
Single
Married
3. Family/Last Name _______________________________________________________________________________________
(
Print your names exactly as they appear in your passport. Important: always spell your names the same way on all forms/applications)
4. First/Given Name________________________________________________________________________________________
5. Middle Name(s) _________________________________________________________________________________________
6. Date of Birth (mm/dd/yyyy) __________________7. U.S. Social Security Number (if available) __ __ __-- __ __ -- __ __ __ __
8a. City of Birth ____________________________________ 8b. Country of Birth _____________________________________
9. Country of Citizenship: ____________________________________________________________________________________
(
If you are a dual citizen, choose the passport you will use for your period of study in the U.S.)
10. Country of Permanent Residence ___________________________________________________________________________
11a. Occupation __________________________________ 11b. Institutional Affiliation _________________________________
12. Foreign Address (required information)
13. U.S. Address, if any:
Street Address______________________________________
Street Address_____________________________________
________________________________City______________
Apt. _____________________________________________
State___________________________Country____________
City________________________________State__________
Postal Code ________________________________________
ZIP ______________________________________________
Telephone No. _____________________________________
U.S.
____________________________________
Telephone No.
14a. E-mail _______________________________________
14b. FAX (if any) ___________________________________
15. Are you currently enrolled or have you previously been enrolled at Northeastern?
Yes
No
a. If yes, list dates of enrollment _______________________________________b. Degree earned/expected ___________________
16. Northeastern ID (if known) __ __ __-- __ __ -- __ __ __ __
ISSI 657-LAL-[Q] 71006
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