Exchange Visitor Intake Form
(Required
Prior to Request for VISA)
Name:
First
Middle
Last
Date of Birth:_____________ Gender:____City of Birth:______________
Country of Birth:_________________Country of Citizenship:_____________
Country
of Legal Permanent Residence:___________________
Position (in home
country):______________________________
Anticipated US
Address:
___________________________________
___________________________________
___________________________________
___________________________________
Exchange Visitor
Category (please mark one):
____ Professor:
A professor coming to teach, lecture or observe for a period of three
weeks to three years.
____Short-term
Scholar: A professor coming to teach, lecture or observe for a period
of up to six months.
____Specialist:
An expert in a field of specialized knowledge or skill but will not fill a
permanent or long term position of employment. The duration of stay will
be three weeks to one year.
____ Student,
College and University--degree: Pursuing
a full course of study in search of a degree or engaged full-time in a
prescribed course of study. The
period of this visit will last three weeks to end of the program.
____Student, College and
University—nondegree: Pursuing a full course of study of a
prescribed course of study not in search of a degree. The duration of the
stay will be between three weeks and two years.
Subject Studying/Field
Teaching:__________________________________
Program Start Date:__________
Program End Date:_________
These dates must follow regulations stated above in the Exchange
Visitor Category
Describe the activity of
the Exchange Visitor:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Site of Activity (please
mark one):
Main Campus____
ACCEL ____ Other________________________
This program has/has not (please
circle one) received funding for international exchange from one or
more U.S. Government Agency(ies) to support this exchange visitor.
Have you ever held a J
status before? Yes____ No_____
If yes, list dates, from __________to __________
Financial Support
Financial Support from
SAU:________________________
Financial Support from US
Government Agencies:
___________________________________________
___________________________________________
Financial Support from
International Organizations:
___________________________________________
___________________________________________
Financial Support from
Exchange Visitor’s Government:
___________________________________________
The Binational Commission
of the Exchange
Visitor’s Country: ______________________________
All Other Organizations
Providing Support:
___________________________________________
___________________________________________
Personal
Funds:_______________________________
Total Estimated Financial
Support:___________________
Dependent Information (As required):
Name:
First
Middle Last
Date of Birth:_______________Gender:_____Relationship:_____________________
City of
Birth
:_____________________ Country of Birth:_______________________
Country of Citizenship:_________________
Country
of Legal Permanent Residence:___________________
Anticipated US
Address (if different than listed above):
___________________________________
___________________________________
___________________________________
___________________________________
|
