J-1 Student Information Request Form Each section of this application form must be completed. If you leave an area blank, this will delay the issuance of the Form DS-2019 (Certificate of Eligibility for the J-1 program) and may prevent you from obtaining the J-1 visa and participating in your program of study. BIOGRAPHICAL INFORMATION Gender: male female Date of Birth: (month/ day/ year) Country of Birth: Country of legal permanent residence: Occupation in home country (i.e. undergraduate student, master s student, PhD candidate): Permanent Address: address) Address Line 1: Address Line 2: City: State/ Province: Country: Postal Code: Tel: E-mail: Mailing Address: (if different than permanent Address Line 1: Address Line 2: City: State/ Province: Country: Postal Code: Tel: E-mail: Creese Student Center - Room 210 Phone: 215-895-2502 Fax: 215-895-6617 E-mail: intlprog@drexel.edu Page 1
PROGRAM INFORMATION Quarter of Admission: Fall (September December) Winter (January March) Spring (March June) Summer (June September) Anticipated Level of Study: Bachelor Master Doctoral Non-Degree Exchange Program Participant Specify Exchange Program: Name of current institution: Length of program participation: IMMIGRATION HISTORY: If you are currently in the U.S., what is your non-immigrant status?: Please include a copy of your I-94 card, and appropriate immigration documents (Form I-20, Form DS-2019, H-1B approval notice, etc.) Previous J-1/J-2 Participation Information: Have you previously been in the U.S. as a J-1/J-2 Exchange Visitor? Yes No If yes, please include a copy of your most recent Form DS-2019. FINANCIAL SUPPORT INFORMATION: Students are required to show proof of financial support for the duration of the J-1 program participation. Tuition and fee amounts may vary depending on your specific program of study. Please see http://www.drexel.edu/catalog/general/tuitionfees-index.htm for additional information regarding Drexel University s fee structure. Documents that qualify as proof of financial support: - A sponsorship letter from Drexel University, a government agency, international organization, or other sponsor. The award letter should specify the length of sponsorship and the amount of money provided, living expenses, insurance, dependents, and other personal items If your appointment/ award will not cover all necessary expenses, you may use private or self-sponsorship for the remainder. All financial documents must be current at the time of application in order to be considered valid. Appropriate documents reflecting financial ability include, but are not limited to the following: Bank statement, stamped or signed by a bank official Account summary or summary of liquid assets Affidavit of support, submitted by sponsor & accompanied by financial verification Scholarship letter from sponsoring organization outlining dates and terms of scholarships Letter from employer stating earnings for period of requested stay Creese Student Center - Room 210 Phone: 215-895-2502 Fax: 215-895-6617 E-mail: intlprog@drexel.edu Page 2
DEPENDENT INFORMATION If any of your family members (spouse and/or children) will be accompanying you to the U.S. and will require a J-2 dependent status, please provide the following information (please note that a separate Form DS-2019 will be issued to each dependent): Dependent 1: Dependent 2: Dependent 3: If additional space is required, please attach a sheet with the above information to this application. Creese Student Center - Room 210 Phone: 215-895-2502 Fax: 215-895-6617 E-mail: intlprog@drexel.edu Page 3
PROGRAM ACCEPTANCE Before signing this form, please ( ) the following items: I have read and understood the conditions of the J-1 Exchange Visitor Program as outlined at www.drexel.edu/isss I declare that I have truthfully stated the financial arrangements to support my exchange visitor program I understand that I am primarily coming to the United States to study rather than engage in employment I understand that I must continue to carry sufficient health insurance during the entire duration of my stay I understand that I must check in with ISSS upon arrival in the U.S. and no later than 10 days after the program start date stated on the Form DS-2019 o Exchange students ONLY: I understand that I should also check in with the Study Abroad Office, who has facilitated my exchange program I understand that I may enter the U.S. no sooner than 30 days prior to the program start date listed on my Form DS-2019, and that must depart the U.S. no later than 30 days after the completion of my program participation (as stated on my Form DS-2019). Student Signature Print Name Date Creese Student Center - Room 210 Phone: 215-895-2502 Fax: 215-895-6617 E-mail: intlprog@drexel.edu Page 4
NOTICE OF J-1 EXCHANGE VISITOR INSURANCE REQUIREMENT The United States Department of State requires health, accident, repatriation, and medical evacuation insurance for participation in the J-1 Exchange Visitor Program. As such, Drexel University (the sponsor) requires all students to enroll in the university sponsored health insurance program. The following is an outline of the minimum insurance requirements as established by The U.S. Department of State that are designed to protect the student and his or her family. Minimum insurance coverage shall provide: 1. Medical benefits of at least $50,000 per accident or illness; 2. Repatriation of remains in the amount of $7,500; 3. Expenses associated with medical evacuation of the exchange visitor to his or her home country in the amount of $10,000; and 4. A deductible not to exceed $500 per accident or illness. An exchange visitor who willfully fails to maintain the insurance coverage while a participant in an exchange visitor program, or who makes a material misrepresentation to the sponsor concerning such coverage, shall be deemed to be in violation of these regulations and shall be subject to termination as a participant. A sponsor shall terminate an exchange visitor's participation in its program if the sponsor determines that the exchange visitor or any accompanying dependent willfully fails to remain in compliance with insurance requirements. (22CFR 514.14 of the Federal Regulations Covering the Exchange Visitor Program.). Each exchange visitor is required to sign this Notice of Insurance Requirement before the Form DS-2019 can be issued. Exchange Visitor s Signature Print Name Date Creese Student Center - Room 210 Phone: 215-895-2502 Fax: 215-895-6617 E-mail: intlprog@drexel.edu Page 5