Ds 2019 Form - Application For A Certificate Of Eligibility printable pdf download

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

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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Ds 2019 Form - Application For A Certificate Of Eligibility

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