International Student & Scholar Services (ISSS) Classroom Unit 101, 1156 High Street, Santa Cruz, CA, 95064 Phone: (831) 459-2858 Fax: (831) 459-2382 REQUEST FOR FORM DS-2019 FOR NON-TENURE TEACHING OR RESEARCH POSITIONS This process is initiated by the UC Santa Cruz sponsoring department. Upon approval from the Department Chair forward this request to the Divisional Coordinator. Please submit completed form to ISSS office (ischolar@ucsc.edu or MS Global Engagement). Please include the following: Copies of J-1 and any J-2 Passport Identity Pages Financial Certification Letter (if not funded by UCSC) Copies of Previous J-1 and/or J-2 DS-2019 Forms (if applicable) J-1 Transfer -In Form (if applicable) SECTION A. Program Information To be completed by sponsoring department DS-2019 Request Type: New Appointment Transfer In J-1 Category: Short-Term Scholar (research or teaching for 6 months or less) Research Scholar (research or teaching for 6 months or more) Professor (teaching for more than 6 months) Department: Appointment Start Date: (mm/dd/yyyy) Division: Appointment End Date: (mm/dd/yyyy) UC Payroll or n-paid Title: Percent Effort: (paid titles only) Activity: (Select all that apply) Teaching/Lecture Research Observing/Consulting Describe Subject or Field of Research: (For example: Teach courses in ; observe techniques, learn skills, or conduct research in xyz) Site of Activity: Indicate the physical location of scholar s activity. Include all relevant on or off-campus sites. Main UCSC campus 1156 High Street, Santa Cruz, CA 95064 Other Primary or Secondary Site (provide location name and address below) Location Name: Address: SECTION B. Certification of English Language Proficiency Statement Completed by sponsoring professor or supervisor By signing below, I confirm that I have conducted an interview with the prospective J-1 scholar either in-person, by videoconferencing, or by telephone (if videoconferencing is not a viable option) and that the scholar has sufficient English proficiency not only to successfully participate in his/her program but also to function on a day-to-day basis. Date and Time of Interview: (month/day/year) Time Method Used to Interview (circle one): in-person videoconferencing telephone Signature of Supervisor
SECTION C. Proof of Financial Funding If financial support is not provided by UCSC then funding (scholarship letter, bank statement, etc.) with specific currency amount, converted to U.S. dollars and translated into English must be provided by the scholar. Include a letter of financial support if sponsored by another individual. Funding docs must be issued within past 6 months. Scholars must provide at least $2000/month proof of funding for self, $1000/month for spouse, and $500/month for each child. Funding Source Amount Per Month Number of Months Total Amount University of California, Santa Cruz- Salary University of California, Santa Cruz- Other (Specify below, e.g. reimbursement, per diem, cost of living, etc.) U.S. Government Agency (Specify below) Scholar s Home Government (Specify below, e.g. China Scholarship Council) International Organization (Paid directly only, e.g. EMBO, NATO, UN, WHO) Bilateral Commission (Paid direct only, e.g. Fulbright) Other (Specify below, e.g. home institution, etc.) Personal Funds (Include personal bank account letter or sponsor s bank account with Affidavit of Financial Support) SECTION D. Signature Authorization Total Amount Required for Program: Total Amount Scholar Has for Program: Your signature indicates you agree to the following: The sponsoring department will provide assistance to the scholar upon arrival at UCSC. The proposed activity is suitable to the scholar s background, needs, and experience. The scholar and family members have sufficient funding for their stay. The scholar is aware of the health insurance requirement and is clear as to who is responsible for paying for insurance premiums. The scholar will engage only in activities that are consistent with the intended program while at UCSC. Inform ISSS when conditions of financial support change, position/title change, early completion or termination of program or if the scholar will be outside the U.S. for more than 30 days. 1. Sponsoring Professor: Name Signature Date Phone Extension 2. Department Chair and Department Name: 3. Dean, Div Coordinator, or Official Designee: 4. Department/Division Contact: (if different from above)
SECTION E. Scholar Information Enter your name as it appears in the passport Given/First Name & Middle Name(s): Date of Birth: (mm/dd/yyyy) City of Birth: Country of Citizenship: Country of Birth: Country of Legal Permanent Residence: Describe your current or last position in your home country: Graduate Student Researcher Professor Other (please specify): If student, name of Home institution: If employed, provide job title and name of employer: Highest Degree Obtained: Bachelor s Master s Doctorate Other International or U.S. Phone Number: Date Awarded: (month, year) Email: Residential Address in Home Country or United States (Do not list a work address or P.O. Box) Street: City: State/Province (if applicable): Postal Code (if applicable): Country: Mailing Address, if different than above (Do not list a P.O. Box) Street: City: State/Province (if applicable): Postal Code (if applicable): Country: Are you currently in the United States? Yes *If yes, indicate the current immigration status? (i.e. F-1 OPT, B-1, J-1, J-2, etc.) *If yes, attach a photocopy of all immigration documents (including Form I-20, DS-2019, I-94 card, visa, EAD card, and/or I-797 approval notices.) Transfer: If you are currently in J-1 status and transferring your J-1 program to UCSC, submit the UCSC J-1 Scholar Transfer-In Form. Change of Status. Contact ISSS to set up an appointment with an advisor to review Form I-539 application. Travel. If you are leaving the US and returning after obtaining a J-1 visa at an embassy/consulate then provide travel dates: Have you previously participated in a J-1 or J-2 program within the past 24 months? Yes *If yes, include all previous DS-2019 form(s). Will any dependent(s) (spouse or child) accompany the scholar? Yes *If yes, complete Section G.
SECTION F. Document Certification by Scholar I hereby attest that the copies of the documents that I have submitted are of unaltered original documents. I understand that I may be required to submit original documents to an immigration, consular, or UCSC school official at a later date. I also attest that any translations included in this application are accurate. Name: Signature: Date: SECTION G. Dependent Information Only complete this section if requesting a J-2 dependent DS-2019(s). Only spouses and unmarried children younger than 21 are eligible. Enter information as it appears on passport and attach additional pages if necessary. Please include a copy of the passport biographical page of each dependent. 1. 2. 3. 4.
Department/Division: Please choose an option for delivery of completed DS-2019 Will pick-up from ISSS office. When ready please contact (provide a name and extension): Send original DS-2019 via campus mail Department/Division Contact: Department/Division: Mailstop: Department requests ISSS to send original DS-2019 directly to the Exchange Visitor, using FedEx service. Photocopy of DS-2019 will still be forwarded to department/division contact. Mail Code: Authorized By: Exchange Visitor s Address and Telephone number (required):