I attended/will attend: (check one): Orientation on the Main Campus Orientation at the UC Davis Medical Center Orientation Online SCHOLAR PERSONAL DATA SHEET CURRENT INFORMATION Name: Male Female Family (Last) First Middle
Country of citizenship: Date of birth: mm/dd/yy Is family here now? Yes No If “No,” will family join you later? Yes No Spouse’s name: Family (Last) First Middle Children under 21 years of age who accompanied you or will be visiting you (names & ages) Family (Last): First: Middle: Age:
Current address in California
Street Number Street Name Apartment Number City Postal Zip Code Phone Number with Area Code Home or Cell Office/Lab Phone Personal Email: UCD Email :
HOME COUNTRY ADDRESS Street Line 1: Street Line 2: City: State/Province: Postal Code: Country:
PERSON TO BE NOTIFIED IN CASE OF AN EMERGENCY Name: Relationship: Address: Phone number: E-mail address:
2 YEAR HOME RESIDENCY REQUIREMENT/ 212 (e) Please check your J-visa stamp and DS 2019 Are you subject to 212 (e)? Yes No If “Yes”, please indicate what it is based on (listed on DS 2019, lower left corner): Government Financing and/or Exchange Visitor Skills List As the J Exchange Visitor Program Sponsor, UC Davis does not assist with 212 (e) waiver applications. Requesting a waiver is the J Exchange Visitor’s responsibility. However, it is strongly recommended that J Exchange Visitors notify SISS of waiver plans as it can affect your J-program, especially extension requests.
HEALTH INSURANCE Do you currently have health insurance? Yes No If “Yes,” name of provider: I understand that I am responsible for maintaining health insurance coverage throughout my stay in the U.S. If I do not currently have insurance, I will purchase insurance immediately. Please see our website for more information about insurance options: http://siss.ucdavis.edu/scholars_depts/j_visa/j-insurance.html .
Signature of scholar Date To view an orientation slideshow, visit our orientation webpage: http://siss.ucdavis.edu/scholars_depts/j_visa/j_new.html
Rev May 2014