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Freshman Admissions

Request For SEVIS DS-2019

REQUEST FOR SEVIS DS-2019 FOR UG/GR OFFICE
J-1 Status Exchange/Visitor Program
(Must fill out completely by appropriate admissions official)
Rev: 3/14/16

Admissions Requestor:
Date:
Department:
Extension:

VISITOR INFORMATION:
BANNER ID:

NAME: (last/family)(first)(middle)
Gender: (male) (female)
Date of birth: (mm/day/year)

City of Birth:
Country of Birth:
Country of Citizenship:

Email address:
Country of Permanent Residence:
Phone: (must include country code and city code)
Will dependents accompany Exchange Visitor: (please see below and reverse) (Yes) (No)
Position in Home Country: (occupation: if student: UG/GR/Doc; if teaching: Secondary or University)

Purpose of Request for New Form (check one):
Begin a new program: (initial request)
Extend an on-going program:
Date of first arrival in U.S.:
Transfer from a different program (if in the U.S. in another program, attach copy of DS-2019):
Replace a lost/damaged form:

Purpose of Visit:
Non-Degree Student:
Undergrad:
Masters:
Doctorate:
TOEFL Score:
Date Taken:
Major Field of Study:
Expected Begin Date: (mm/dd/yy)
Expected Completion Date: (mm/dd/yy)
Sources & Amounts of Funds for the Requested Period (please attach official letter(s) from sponsor(s)):
Florida Tech Scholarship: $
U.S. Government Agency (specify): $
Exchange Visitor’s Government: $
All other organizations providing support (specify): $
Personal Funds (attach bank statement): $
Dependent Costs ($5,000/$7,500/$10,000): $
GRAND TOTAL: $

If qualifying dependents (spouse & children) will accompany the exchange visitor, please complete the Dependent Information Form found on the reverse of this page.

DS-2019 Request Form, passport copy, and financial documentation submitted to Jackie – ISSS for processing. She will then return it to appropriate official for further Admissions processing/mailing.

DEPENDENT INFORMATION FORM
(this form must be filled out in its entirety if J-1 is bringing dependents)

Name of Principal Exchange Visitor:

Please provide the following information about each dependent who will accompany the
exchange visitor. (Use a separate sheet if necessary)

Dependent #1:
Name (SURNAME, First name)
Date of Birth
City of Birth
Country of Birth
Country of Citizenship
Country of Permanent Residence
Gender
Relationship to Principal Exchange Visitor (spouse, child)

Dependent #2:
Name (SUR
NAME, First name)
Date of Birth
City of Birth
Country of Birth
Country of Citizenship
Country of Permanent Residence
Gender
Relationship to Principal Exchange Visitor (spouse, child)

Dependent #3:
Name (SURNAME, First name)
Date of Birth
City o
f Birth
Country of Birth
Country of Citizenship
Country of Permanent Residence
Gender
Relationship to Principal Exchange Visitor (spouse, child)

Dependent #4:
Name (SURNAME, First name)
Date of Birth
City of Birth
Country of Birth
Country of Ci
tizenship
Country of Permanent Residence
Gender
Relationship to Principal Exchange Visitor (spouse, child)