Form Ds-2019 - Application For Initial (Page 2 of 2) in pdf

IF APPLICABLE, PLEASE ATTACH A SEPARATE SHEET LISTING THE FOLLOWING ABOUT EACH DEPENDENT WHO WILL ACCOMPANY OR

JOIN THE EXCHANGE VISITOR: NAME, RELATIONSHIP TO THE EXCHANGE VISITOR, DATE OF BIRTH, COUNTRY OF BIRTH, AND COUNTRY OF

CITIZENSHIP, ADDRESS IN HOME COUNTRYADDRESS IN US AND EMAIL ADDRESS FOR EACH DEPENDENT. NOTE: DEPENDENTS MUST BE

ENROLLED IN THE MEDICAL INSURANCE PLAN AVAILABLE FOR FIU STUDENTS AND SCHOLARS.

DOCUMENTATION OF FUNDING: ALL AMOUNTS AND SOURCES MUST BE INDICATED BELOW AND DOCUMENTED IN SUPPORTING MATERIALS.

PLEASE REFER TO THE INSUTRCTIONS FOR COMPLETING DS-2019 REQUEST FORM FOR COMPLETE INFORMATION ABOUT REQUIRED

DOCUMENTATION OF SUPPORT.

PLEASE INDICATE THE DOLLAR AMOUNT OF SUPPORT WHICH WILL BE PROVIDED FOR THE EXCHANGE VISITOR BY FIU:

$____________________________________________DEPARTMENT_______________________________________________________________________________

PLEASE INDICATE BELOW THE SPECIFIC SOURCE(S) AND AMOUNT(S) OF THE EXCHANGE VISITOR’S FUNDING FROM NON-FIU SOURCES:

______U.S. GOVERNMENT AGENCY

_____________________________________________________________________________________________

(AGENCY)

(AMOUNT)

______EXCHANGE VISITOR’S GOVERNMENT _____________________________________________________________________________________________

(GOVERNMENT)

(AMOUNT)

______BI-NATIONAL COMMISSION OF

_____________________________________________________________________________________________

EXCHANGE VISITOR’S COUNTRY

(COMMISSION)

(AMOUNT)

______ALL OTHER ORGANIZATIONS

_____________________________________________________________________________________________

(NAME/S)

(AMOUNT)

______PERSONAL FUNDS/PRIVATE SPONSOR _____________________________________________________________________________________________

(NAME/S)

(AMOUNT)

EXCHANGE VISITOR MEDICAL INSURANCE: PLEASE CHECK ONE:

______THIS EXCHANGE VISITOR AND DEPENDENTS WILL PURCHASE THE FIU APPROVED MEDICAL INSURANCE POLICY PRIOR TO ISSUANCE

OF THE DS-2019 FORM. ENROLLMENT FORM AND PAYMENT ATTACHED.

______THIS EXCHANGE VISITOR AND DEPENDENTS WILL BE COVERED BY THE MEDICAL INSURANCE PLAN OFFERED AS PART OF THE

STANDARD BENEFITS PACKAGE AVAILABLE TO EXCHANGE VISITORS WHO ARE UNIVERSITY EMPLOYEES AND WILL PURCHASE A

SEPARATE POLICY PROVIDING EMERGENCY MEDICAL EVACUATION AND REPATRIATION. DOCUMENTATION INDICATING EFFECTIVE

DATE OF COVERAGE IS REQUIRED PRIOR TO ISSUING THE DS-2019 FORM. IF THE EXCHANGE VISITOR’S PROGRAM COMMENCES PRIOR TO

THE EFFECTIVE DATE OF COVERAGE, THE EXCHANGE VISITOR AND DEPENDENTS WILL PURCHASE THE FIU APPROVED POLICY FOR THAT

PERIOD OF TIME.

CERTIFICATION OF FACULTY SPONSOR: PLEASE READ AND SIGN.

I CERTIFY THAT I AM INVITING THE PROSPECTIVE EXCHANGE VISITOR NAMED HEREIN FOR FIU TO PURSUE THE ACTIVITIES

DELINEATED ABOVE. FUNDING WILL BE PROVIDED AS INDICATED FOR THE PERIOD CERTIFIED ABOVE. I UNDERSTAND THAT ALL

EXCHANGE VISITORS ARE REQUIRED BY FEDERAL REGULATION AND FIU TO CARRY ADEQUATE MEDICAL INSURANCE, AND I WILL

ENSURE THAT THIS EXCHANGE VISITOR CARRIES MEDICAL INSURANCE AS DESCRIBED ABOVE. I UNDERSTAND AND WILL EXPLAIN TO THIS

EXCHANGE VISITOR THAT EXCHANGE VISITOR SCHOLARS/RESEARCHERS ARE NOT PERMITTED TO CHANGE TO THE STUDENT CATERGORY

AFTER THEIR ENTRY INTO THE UNITED STATES.

________________________________________________________

_________________________________________________

SIGNATURE OF FACULTY SPONSOR

DATE

CERTIFICATION OF DEPARTMENT HEAD/ACADEMIC DEAN: PLEASE REVIEW THIS DOCUMENT IN FULL AND INDICATE SUPPORT AND

APPROVAL BY SIGNING BELOW.

_________________________________________________

_________________________________________

________________________________________

DEPARTMENT HEAD SIGNATURE

NAME (PRINTED)

DATE

_________________________________________________

_________________________________________

________________________________________

ACADEMIC DEAN SIGNATURE

NAME (PRINTED)

DATE

APPROVAL OF DIRECTOR, OFFICE OF INTERNATIONAL STUDENT & SCHOLAR SERVICES: SIGNATURE BELOW INDICATES APPROVAL TO

PREPARE AND ISSUE FORM DS-2019 FOR THE ABOVE-NAMED EXCHANGE VISITOR.

________________________________________________

_________________________________________

Dr. Ana M. Sippin, Director

DATE

International Student & Scholar Services or designee

Rev:01/15

Form Ds-2019 - Application For Initial Page 2

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