Form Ds-2019 - Application For Initial printable pdf download

APPLICATION FOR INITIAL FORM DS-2019

Certificate of Eligibility for J-1 Exchange Visitor

Please circle category: Professor/Researcher/Short-Term Scholar/Specialist

To complete this form, please refer to the Instructions for completing DS-2019 Request Form.

Submit this request to Dr. Ana M. Sippin, Director, Office of International Student & Scholar Services, to prepare form DS2019 for

the below-named foreign national, who will be invited to FIU as professor, researcher, short-term scholar or specialist. Please attach

a current resume or curriculum vitae.

_______________________________________________________________________________________________________________________________________

Name of Faculty Member Making Request

Title

_______________________________________________________________________________________________________________________________________

Department/Campus Address/Extension

Contact Person

Extension

EXCHANGE VISITOR INFORMATION: PLEASE TYPE OR PRINT CLEARLY

NAME: ____________________________________________________________________________________________

MALE_____________

FAMILY NAME

GIVEN

FEMALE___________

ADDRESS IN HOME COUNTRY:___________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

DATE OF BIRTH: __________________________________

PLACE OF BIRTH:_________________________________________________________________

(Mo/day/yr)

(City)

(Country)

CITIZEN OF: ____________________________________________________ PERMANENT RESIDENT OF: ______________________________________________

EMAIL ADDRESS: ________________________________________________POSITION IN HOME COUNTRY: __________________________________________

HAS THIS PROSPECTIVE EXCHANGE VISITOR BEEN PREVIOUSLY IN THE UNITED STATES AS AN EXCHANGE VISITOR IN J-1 STATUS/ IF YES,

PLEASE PROVIDE THE FOLLOWING INFORMATION AND ATTACH COPIES OF ALL DS-2019 FORMS ISSUED:

DATES

LOCATION

CATERGORY

_________________________________________________________________________________________________________________________________________

U.S. ADDRESS IS/WILL BE: ________________________________________________________________________________________________________________

ANTICIPATED DATES OF FIU PROGRAM: ______________________________________________TO_________________________________________________

(MO/DAY/YR)

IS THE EXCHANGE VISITOR CURRENTLY IN A DEGREE PROGRAM AT ANY UNIVERSITY? ________________IF YES, PLEASE INDICATE DEGREE

SOUGHT, MAJOR FIELD, INSTITUTION AND LOCATION: ____________________________________________________________________________________

DOES THIS EXCHANGE VISITOR WISH TO PURSUE A DEGREE AT FIU? ______ SUBJECT FIELD OF RESEARCH/TEACHING: ____________________

PLEASE PROVIDE A SPECIFIC DESCRIPTION OF THIS EXCHANGE VISITOR’S STUDY, RESEARCH, AND PROFESSIONAL ACTIVITIES AT FIU:

_________________________________________________________________________________________________________________________________________

EXCHANGE VISITOR’S DEPENDENTS: THIS EXCHANGE VISITOR WILL

__________BE ACCOMPANIED BY___________DEPENDENTS UPON ARRIVAL TO FIU.

__________COME ALONE AT FIRST AND BE JOINED BY__________DEPENDENTS LATER.

__________NOT BE ACCOMPANIED BY DEPENDENTS DURING HIS/HER FIU PROGRAM.

Form Ds-2019 - Application For Initial

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