Ds-2019 Request Form Page 3
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PART V-DEPARTMENTAL INFORMATION AND CERTIFICATION
21. a. I certify the accuracy of the information provided above.
b. I recognize that incomplete information will delay the issuance of Form DS-2019. It is recommended that a department initiate this
request at least two (2) months prior to the Scholar’s intended visit. It may be helpful to send the Scholar’s c.v. to the ISSO with this
Request.
c. I understand that the Scholar may be employed during the dates of the program only, even though the individual may enter the U.S. up to
30 days in advance and may remain 30 days after completion.
d. I understand that if the Scholar wishes to enroll as a part-time, non-degree student, he/she must first meet UNL admission requirements,
including English proficiency documented by a satisfactory TOEFL score, and pay tuition and fees.
e. I will direct the Scholar to report to the ISSO immediately upon arrival at UNL with his /her INS documents.
(Form I-94, passport and Form DS-2019).
f. All J-1 Scholars are required by federal regulation to have health and accident insurance with coverage for medical evacuation
and repatriation of remains. I understand this federal insurance requirement and will urge the Scholar to obtain the insurance
immediately upon arrival, if not sooner. The ISSO has informational brochures regarding insurance policies specifically designed for
International Scholars.
g. I will direct the Scholar to attend the next J-1 Scholar Orientation held the first Wednesday of each month from 9:00-10:00 A.M.
at the ISSO.
h. I will report the termination/departure of the Scholar from the department to the ISSO.
Certified:
_____________________________________________ ____________________________________________
___________________
Name of Requesting Faculty Member
Signature
Date
________________________________
____________________________________________
Phone
E-mail Address
22. Approval of Department Chair/Head or Director
_____________________________________________
____________________________________________
___________________
Name
Signature
Date
23. Return Information (UNL person to whom Form DS-2019 and attachments should be sent for transmittal to Scholar)
Name:__________________________________
Phone:________________________
Department: _____________________________
Campus Address:___________________________________________
Fax:_________________
Campus Zip:________________________
E-mail Address:_______________________________
___________________________________________________________________________________________________________________
FOR USE BY the International Student and Scholar Office
DS-2019 approved as:
Comments:
_____ Professor
_____ Research Scholar
_____ Short-Term Scholar
_____ Specialist
_______________________________________________
__________________
International Student/Scholar Specialist in ISSO
Date
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