Texas Tech University Office of International Affairs International Student and Scholar Services APPLICATION FOR A FORM DS-2019 PLEASE SUBMIT THIS APPLICATION AND OTHER REQUIRED DOCUMENTATION AT LEAST THREE MONTHS BEFORE YOU WISH THE VISITOR TO ARRIVE IN THE U.S. To issue a DS-2019, Certificate of Eligibility for Exchange Visitor (J-1) Status, the following information is required: 1. This request is to: Invite visitor from another country Transfer from another J-1 program Change the status of an alien already in the U.S. to J-1 status 2. If the Exchange Visitor is currently in the U.S.: a. Current non-immigrant status: b. Sponsor: c. Current Title: d. Date of Last Entry to the U.S.: e. Permission to stay in the U.S. expires: Month Day Year Month Day Year 3. The TTU individual hosting the visitor: a. Name: b. Title: c. Campus Phone: Email: 4. The person authorizing this appointment (department chair or higher ranking administrator): a. Name: b. Title: c. Department: 5. Exchange Visitor s Information Name: (As on Passport) Family/Surname(s) 6. Gender/Marital Status: Male Female Single Married Given Name(s) Application for a Form DS-2019 Page 1 of 7
7. Date of Birth: Month Day Year 8. Birth Place: City Country 9. Country of Citizenship: 10. Country of Legal Permanent Residence: 11. What most recent position (e.g., professor, undergraduate student, scientist, administrator) did/does the visitor hold in his/her country of citizenship or legal permanent residence: a. Title: b. Duties: c. Institution/Company: d. City, Country 12. Proposed period of stay in the United States: From: Month To: Month Day Day Year Year Maximum anticipated length of stay: Please note: As articulated in regulations of the Department of Homeland Security, attempting to enter the United States more than 30 days before or after the begin date shown above may result in refusal or admission to the United States at the Port of Entry. An exchange visitor much check in within 10 days of arrival. CFR 62.10(c)(9). 13. J-1 visa category of this visitor at Texas Tech University (see definitions below): a. Student: Degree seeking or n-degree Seeking. b. Research Scholar: 3 weeks to 5 years, more research than teaching. c. Professor: 3 weeks to 5 years, more teaching than research. d. Short-Term Scholar: Up to 6 months (Teaching and/or Research). e. Specialist: Up to one year. f. Student Intern: Undergraduate research up to one year. DEFINITIONS OF VISITOR CATEGORIES STUDENT: An individual who is studying in the United States pursuing a full course of study leading to or culminating in the award of a U.S. degree from a post-secondary educational institution; or who is engaged fulltime in a prescribed course of study of up to 24 months duration conducted by a post-secondary accredited educational institution. Application for a Form DS-2019 Page 2 of 7
PROFESSOR: A person who is engaging in a program for the purpose of teaching or conducting advanced research or both in an established institution of higher learning. [Maximum stay: 5 years] RESEARCH SCHOLAR: A person who is engaging in a program for the purpose of undertaking or participating primarily in research. [Maximum Stay 5 years] SHORT-TERM SCHOLAR: A professor, research scholar, or person with similar education or accomplishments coming to the United States on a short-term visit for the purpose of lecturing, observing, consulting, training, or demonstrating special skills at research institutions, museums, libraries, post-secondary accredited educational institutions, or similar type of institutions. [Maximum stay: 6 months] SPECIALIST: An expert in a field of specialized knowledge or skill coming to the United States for observing, consulting, or demonstrating special skills, except professors, research scholars, and alien physicians in graduate medical education or training. [Maximum stay: 1 year] STUDENT INTERN: Requires additional processing time and application materials. A student from a foreign university coming to the United States to complete an internship required by the foreign degree program. [Maximum stay: 1 year] 14. Detailed description and location/s of visitor s program at TTU: a. Description of activities: b. Major Field: c. Minor Field: d. Site of Activity: Site 1: (1.) Street address w/approximate dates for Site 1: (2.) Building Name: (3.) Lab Office Number: e. Site of Activity: Site 2: (1.) Street address w/approximate dates for Site 2: (2.) Building Name: (3.) Lab Office Number: If there will be more than two sites of activity, please attach a separate piece of paper outlining all the details. 15. Exchange Visitor s primary responsibility at TTU: Teaching Research Other (explain): Application for a Form DS-2019 Page 3 of 7
16. List degrees or other qualifications: 17. Financial Support: List each source and amount (in U.S. dollars) to be received during stay. IF SUPPORT IS FROM ANY SOURCE OTHER THAN TTU, ATTACH PROOF OF SUPPORT. $ TTU; Department: a. Will any U.S. government funding be involved? If yes, state the name of agency providing funds: b. Was this government funding received specifically for the visitor? c. Was the funding received specifically designated for an exchange visitor program? $ International Organization; Name of Organization: $ Exchange Visitor's Government $ Personal Funds $ Other; please explain: 18. Will TTU health insurance be offered to the Exchange Visitor? 19. Passport #: Visitor s Passport/travel documents Issued by what country? 20. Visitor s mailing address: a. Street: b. House Number: c. Apartment: d. City: e. Country: f. Postal Code: g. Phone: h. Email: Application for a Form DS-2019 Page 4 of 7
21. What plans are in place for the Exchange Visitor to participate in cultural activities while in the United States? 22. If the visitor has been in the U.S. an Exchange Visitor (J-1 visa holder), please give details of program and inclusive dates. Attach copies of previous DS-2019s. 23. If the visitor will be accompanied by a spouse and/or children, please provide the following information for each: (Continue on separate sheet if needed.) Full Name Relationship to Son/Daughter City & Country Of Birth Date of Birth (MM/DD/YY) Permanent Residence Already in U.S.?** Spouse **Sponsors must report in SEVIS if dependents depart from the United States prior to the Exchange Visitors departure dates. CFR 62.13 (a)(4) 24. The Exchange Visitor applicant has the needed English language proficiency to participate in his/her program and to function on a day-to-day basis outside of the activity (e.g., outside the lab). CFR 62.10 (a)(2). Please submit one of the following for English documentation: a. Scores from a recognized English Language test b. Signed documentation from an academic institution c. A documented interview (videoconferencing or in person), telephone interview acceptable if Videoconferencing not viable. 25. Social Security Number (if applicable): Application for a Form DS-2019 Page 5 of 7
26. Immigration related materials are sent by express mail. Please provide a shipping account number (Departmental FOP): 27. If this form is being filled out by someone other than the Supervisor/Host of Exchange Visitor: a. Name: b. Position: c. Department: d. Campus Phone: Email: Sponsors are prohibited from forwarding a faxed or electronic copy of Form DS-2019 per Regulation (22CFR 62.12) (e)(2). 28. J-1 EXCHANGE VISITOR PROGRAM: ACADEMIC AND GOVERNMENT CATEGORY INCIDENT REPORTING This reporting rubric should be used by Department of State designated Exchange Visitor Program sponsors as a general guideline for reporting incidents involving J-1 exchange visitors to the U.S. Department of State pursuant to 22 CFR 62.13(d). The examples provided below are not meant to be exhaustive (e.g., there may be other serious situations, not listed below, that have or could endanger the health, safety, or welfare of an exchange visitor or otherwise could be expected to bring the Department of State, the Exchange Visitor Program, or the sponsor's exchange visitor program into notoriety or disrepute). An incident report form is preferred in all situations, but an e-mail regarding an evolving situation, to be followed later by an incident report, is acceptable. All Incidents must be reported within one business day of occurrence to the program officer, Phillip Gill, phillip.gill@ttu.edu, 806-742-3667. Reportable Incidents Exchange Visitor Death. Exchange Visitor Missing. Exchange Visitor Serious Illness or Injury (e.g., brain injury, severe burn, major surgery, communicable disease, serious mental health incidents, any condition requiring hospitalization of 48 hours or more, etc.). Litigation (related to a sponsor s exchange visitor program, in which sponsor or an exchange visitor may be a named party). Incident Involving the Criminal Justice System (e.g., arrest, charges, law enforcement, etc.). Sexually-Related Incidents or Abuse (an incident or allegation involving sexual exploitation, harassment or abuse). Negative Press involving a sponsor s exchange visitor program. Foreign Government Involvement (including embassy officials). Other Situations Impacting Exchange Visitor Safety (e.g., natural disasters, civil unrest, outbreaks of violence). Application for a Form DS-2019 Page 6 of 7
22 CFR 62.13(d) Serious problem or controversy. Sponsors must inform the Department of State on or before the next business day by telephone (confirmed promptly in writing by facsimile or email) of any investigations of an exchange visitor's site of activity or serious problem or controversy that could be expected to bring the Department of State, the Exchange Visitor Program, or the sponsor's exchange visitor program into notoriety or disrepute, including any potential litigation related to a sponsor's exchange visitor program, in which the sponsor or an exchange visitor may be a named party. I attest to the best of my knowledge that the above information provided for items 1-26 is true and accurate and that I understand the responsibilities for hosting an exchange visitor as described in #28. 29. Signature: Supervisor/Host of Exchange Visitor: 30. Authorizing Signature: (Department Chair or Higher Ranking Administrator): Phillip Gill International Student and Scholar Services Office of International Affairs Texas Tech University P.O. Box 45004 Lubbock, Texas 79409-5004 U.S.A. Phone: 806-742-3667 Fax: 806-742-1286 Email: phillip.gill@ttu.edu Rev: 04/2016 Application for a Form DS-2019 Page 7 of 7