ࡱ> WYVu@ 8bjbj $B84H2"!!!!=!D*DY2$3R5}2}22"!!$VN@ I4 202 l6Jl6l6(bTp}2}2D"DS-2019 INFORMATION FORM Visiting Faculty and Research Scholars In the interest of educational and cultural exchange, ӶƵ State University welcomes international faculty and research scholars. To apply for a J-1 (Exchange Visitor) visa from the US consulate nearest your place of residence, you must receive from ӶƵ State University Form DS-2019 (Certificate of Eligibility). Preparation of the DS-2019 requires information requested below. Please complete and return both pages to: Institute for International Studies ӶƵ State University 165 Woods Hall ӶƵ, KY 42071-3304 USA By fax: 270.762.3237 Last (family) name:_____male ___femaleFirst name: Middle name:Date of birth: _________/______/_______ month day year Place of birth: _________________,____________________ city countryCountry of citizenship:Country of legal permanent residence: Position in home country: Exact dates of this exchange: From ________/__________/___________ to _____________/_______________/___________ month day year month day year Exchange category: ______professor (teaching) _______research scholar Field of teaching, research, or professional activity while participating in this program:  Financial support in US dollars that you will be receiving from: Type of SourceName of SourceTotal AmountӶƵ State University$US Government Agency$International Organization$Home Country Government$Bi-national Commission$All other organizations, such as your home university$Personal Funds$Note: You may be asked to document this financial support when you apply for a visa. ACCOMPANYING FAMILY MEMBERS If you plan to have your spouse and children accompany you to the United States, they will need to apply for J-2 visas. Provide the information requested below for each dependent: Family NameFirst NameDate of BirthPlace of BirthRelationship to YouPlease note that documentation of financial support must be sufficient to provide for all J-2 dependents and that all J-1/ J-2 visitors must be covered by appropriate medical insurance: IMPORTANT REGULATIONS All exchange visitors are required by law to provide proof of adequate medical insurance for the duration of their exchange program. Please see the attached USIA Welcome brochure for details. This insurance must cover the visitor and all accompanying family members for the entire period of the exchange visit, including periods of travel during your program at ӶƵ State. A number of insurance companies in the US provide policies that meet the standards set by USIA. At present, the policy available through ӶƵ State University costs $750 per year for the J-1 visitors coverage. Insurance for dependents costs much more per person. If you choose to purchase medical coverage upon your arrival, please indicate. If you have medical insurance from your home country that will cover you (and your dependents, if they accompany you) during your stay in the US, please return proof of that insurance with this form. ___________ I plan to purchase medical insurance upon arrival. ___________Proof of insurance coverage is enclosed with this form. The consular officer to whom you apply for a J-1 visa may decide that you are subject to the Two-Year Home Country Physical Presence Requirement. Please refer to the explanation in the attached USIA Welcome brochure. Upon receipt of the necessary information, the Institute for International Studies will prepare Form DS-2019 and send it directly to the address you provide. Please indicate a thorough address (not a post office box) to which material can be delivered: Please read and sign: Having received an invitation from ӶƵ State University to participate in the exchange visitor program, I sign below to indicate that I accept the invitation for the program described on these pages; I have read and I understand the requirements for appropriate medical insurance coverage; I understand that I may be subject to the Two-year Home Physical Presence Requirement. ______________________________________________________________________________ Signature Place Date PAGE  PAGE 2 @A[ b v w A ` ; f <LADAB 5%&'伱ƼhV0JCJjhV0JCJUh(CJOJQJhi;CJOJQJhV6CJOJQJhVCJOJQJhV56OJQJhV5CJOJQJh(OJQJhVCJOJQJhVOJQJhV hV53@A , = U v w $$Ifa$$If$a$7 $Iflkd$$Ifl0$26 04 la  A a $$Ifa$$Iflkd$$Ifl0H$04 laa b z $Iflkd$$Ifl0H$04 la 2Ykd$$Ifl$h%04 la$Iflkd$$Ifl0H$04 la . % & EYkd$$Ifl$h%04 laYkd$$Ifl$h%04 la$If $$Ifa$$a$\kd$$Ifl$V%04 la$If    "#%GXkdz$$IflF $x x x     4 la$IfXkd$$IflF $x x x     4 la%&ABDE]^`GXkdH$$IflF $x x x     4 la$IfXkd$$IflF $x x x     4 la`axy{|GXkd$$IflF $x x x     4 la$IfXkd$$IflF $x x x     4 la GBB$a$Xkd$$IflF $x x x     4 la$IfXkd}$$IflF $x x x     4 la <%9:IkdK$$Iflr${{{{{04 la $$Ifa$$a$:;<=>?@ABCSkd$$Iflr${{{{{04 la$If CDEFGHIJKSkd$$Iflr${{{{{04 la$IfKLYWWRMWGW^ & F$a$kd $$Iflr${{{{{04 laAB5Z'()4567&`#$ & F & F^')*012345678hVOJQJhi;hVhi;0JmHnHu hV0JjhV0JU hVCJ 78" 00 / =!"#$%$$If!vh5256 #v2#v6 :V l05256 4$$If!vh55#v:V l054$$If!vh55#v:V l054$$If!vh55#v:V l054z$$If!vh5h%#vh%:V l05h%4z$$If!vh5h%#vh%:V l05h%4z$$If!vh5h%#vh%:V l05h%4$$If!vh5V%#vV%:V l05V%4e$$If!vh5x 5x 5x #vx :V l5x / 4e$$If!vh5x 5x 5x #vx :V l5x / 4e$$If!vh5x 5x 5x #vx :V l5x / 4e$$If!vh5x 5x 5x #vx :V l5x / 4e$$If!vh5x 5x 5x #vx :V l5x / 4e$$If!vh5x 5x 5x #vx :V l5x / 4e$$If!vh5x 5x 5x #vx :V l5x /  4e$$If!vh5x 5x 5x #vx :V l5x / 4$$If!vh5{5{5{5{5{#v{:V l05{4$$If!vh5{5{5{5{5{#v{:V l05{4$$If!vh5{5{5{5{5{#v{:V l05{4$$If!vh5{5{5{5{5{#v{:V l05{4H@H Normal CJOJQJ_HkHmH sH tH DA@D Default Paragraph FontVi@V  Table Normal :V 44 la (k(No List 4 @4 Footer  !.)@. 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