Introduction to the J-1 Visa

Request form for Certificate of Eligibility for J-1 Visa Status (Form DS-2019) DAVID GEFFEN SCHOOL OF MEDICINE AT UCLA C/O Dean’s Office, Visa & Licensing Office 1060 Veteran Ave. 128G, 709107 Los Angeles, CA 90095 Phone (310) 825-2906, Fax (310) 267-2269

PLEASE TYPE OR PRINT CLEARLY

Before completing this form, please read the instructions thoroughly. After completing all items and obtaining the signatures of the UCLA Department Chair and the foreign national, please return the form to the address above, ATTN: J. Zamoyski.

Please include the Recharge Request Form (P-39) for an administrative processing fee listed in Section M or by attaching a check made out to UC REGENTS. WHEN SUBMITTING A PERSONAL CHECK, PLEASE LEAVE THE DATE BLANK. Our processing time guidelines are outlined in Section L under Instructions.

THIS PORTION OF THE FORM MUST BE COMPLETED BY UCLA OR UCLA-AFFILIATED ADMINISTRATIVE STAFF OR FACULTY. FOREIGN NATIONALS ARE NOT TO COMPLETE OR SIGN THIS FORM.

A. Purpose of this DS-2019:

1. Initial entry to the U.S., or change visa to J-1, accompanied by family member[s]. 2. Extension of stay in the U.S. to continue an ongoing program. 3. Separate entry of family member[s]. 4. Transfer of J-1 visa to UCLA from another U.S. institution. When did the Exchange Visitor begin the J-1 visa at the other institution? , (please pick the month, enter the day and year, i.e. January 11, 2005) EV’s previous J-1 visa category at the other institution (Item 4 on the last DS-2019/IAP-66):

5. Replace lost DS-2019 form/ Amend a previous DS-2019 form.

B. Exchange Visitor's Last Name: First Name: Middle Name:

Male Female

Birthdate? , (please pick the month, enter the day and year, i.e. January 11, 2011)

City of Birth: Country of Birth: Country of citizenship: Country of Legal Permanent Residence: Passport No.: Expiration Date: ,

Occupation in Home Country: Employer: Highest degree: Bachelor Masters PHD MD Other

Date(s) Awarded: U.S. Home Address Permanent Address outside the U.S.

Phone: Area () () - Email:

C. Dates of Appointment: From , To , (see Instructions) If in the U.S.: I-94 form No Expiration Date: , For extension, initial date of entry: ,

D. Exchange Visitor's appointment or primary activity while at UCLA:

Visiting Professor Visiting Lecturer Visiting Researcher Guest Speaker Visiting Scholar Post Doctoral Scholar Other: Visiting Grad Researcher

Subject of studies, research, or teaching at UCLA. (No more than 15 words)

E. Financial Support for the entire period covered by this form. Specify amounts in US dollars UCLA: Department budget, grant, etc. Source: Payroll title:

This is a non-tenure track position: Yes No U.S. Government agency funds to this Exchange Visitor: Name of the Agency: International Organization [e.g. UN, WHO, NATO] funds to this Exch. Visitor: Name of Organization(s): Exchange Visitor's Government. Name of the Agency:

Other organizations/institutions in the U.S. or abroad: Name(s):

Personal funds [see instructions]

F. Medical Insurance: Who will cover the costs? Please check one. UCLA Exchange Visitor Post Graduate Division Other:

For visa extension, Name of insurance carrier: Policy No.

G. Dependents coming or continuing in the U.S. DO NOT list dependents that hold US Passports. Name of dependent(s) Relationship City & Country of Birth Date of Birth (Last, First MI) , , , , , , , , , , , , , , , Country of Permanent Country of Citizenship Passport No. & Expiration Date Residence ,

Attach additional sheet, if necessary. IF NO DEPENDENTS ARE COMING, PLEASE PUT N/A.

H. UCLA faculty member under whose direction the Exchange Visitor's primary activity will be carried out: Name: Title:

Campus Address: Dept:

Mailcode: Division: Email: Phone:

______Faculty Signature Date

I. CERTIFICATION and APPROVAL:

I hereby certify that the information provided on this form is true and correct to the best of my knowledge.

NAME OF STAFF PERSON PREPARING THIS FORM SIGNATURE EXTENSION DATE

For non-Medicine Departments at affiliated hospitals only: Please note that both signatures of the UCLA Department Chair and the affiliated hospital’s Department Chair are required on the application submitted by all departments other than the Department of Medicine at affiliated hospitals. Please obtain both signatures prior to submission. J. UCLA DEPARTMENT CHAIR'S APPROVAL:

This certifies that the applicant is eligible, qualified and accepted to carry out, during the period specified in item C, the activity(ies) indicated. The department has verified the educational credentials and source(s) and amount of funding available.

CHAIR’S NAME SIGNATURE EXTENSION DATE Divisional Chief’s Name for Department of Medicine Only

K. DEPARTMENT CHAIR’S APPROVAL FROM THE AFFILIATED HOSPITAL:

CHAIR’S NAME SIGNATURE EXTENSION DATE

Email:

UCLA DEPARTMENT/AFFILIATED HOSPITALS: [Rev. 4-2014]