H-1b Intake Form Work Authorization Form

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H-1B I
F
, P
2
NTAKE
ORM
ART
To be completed by the prospective H-1B applicant
These forms are used to request consideration of H-1B status for employment at UMMS. Complete these pages and
return them to the hiring UMMS department. The hiring department will submit them to the International Students and
Scholars Office (ISSO) as a set, along with the other requested documents.
Attach clear photocopies of your CV, passport information page(s), both sides of your current Form I-94 (if you are
currently in the U.S.), current and previous immigration documents (DS-2019, Form I-20, H-1B approval notice, etc.).
P
I
ERSONAL
NFORMATION
Full Name as it appears in passport: ___________________________________________________________________
(FAMILY NAME, Given name, middle name)
All other names used (include maiden name
and names from all previous marriages): _______________________________________________________________
Current U.S. address (if applicable):
____________________________________________________________________________________
Current address outside the U.S.:
____________________________________________________________________________________
Phone number: _____________________________ E-mail: ________________________________________________
Gender:
male
female
Social Security Number (if any): _________________________________________
A # (if any): ____________________________________
Highest academic degree(s): ___________________ Date degree(s) awarded: ________________________________
Field(s) of degree (if applicable):_______________________________________________________________________
Did you earn your masters degree or higher degree from a U.S. institution:
No
Yes
(provide the following):
Name & address of the U.S. institution: _________________________________________________________________
(If you have received your highest degree from a non U.S. institution, please provide a foreign equivalency evaluation)
Are you currently working at UMMS?
No
Yes – UMMS Department: ______________________________________
Date of birth: ___________________________________ Country of birth: ____________________________________
(month/day/year)
City of birth: __________________________________
Province of birth: _________________________________
Please indicate if you are a permanent resident, landed immigrant, national or citizen of any other country:
________________________
Country that issued your passport: ______________________________ Passport number: ____________________
Date passport issued: ___________________________ Date passport expires: _______________________________
(month/day/year)
(month/day/year)
If you will await H-1B approval outside the U.S., please complete the following:
U.S. Consulate where you intend to apply
for visa stamp now or in the future: ____________________________________________________________________
(city, country)
H Intake Part 2 – Applicant (01/2015)

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