UCI International Center Form A

UCI International Center
Form A
To be completed by new, incoming J-1 Scholar. Submit to UCI Department with a COPY OF YOUR PASSPORT BIOGRAPHICAL
INFORMATION PAGE.
SECTION ONE: PERSONAL INFORMATION
LAST/FAMILY NAME:
FIRST NAME:
DATE OF BIRTH [MM/DD/YYYY]: GENDER: MALE FEMALE
CITY OF BIRTH:
COUNTRY OF CITIZENSHIP:
WILL THE J-1 HAVE DEPENDENTS WHILE IN THE
U.S.?:
POSITION TITLE IN HOME COUNTRY
(REQUIRED):
NAME OF EMPLOYER IN HOME COUNTRY:
COUNTRY OF BIRTH:
COUNTRY OF PERMANENT RESIDENCE:
YES, SCHOLAR NEEDS TO COMPLETE DEPENDENT REQUEST FORM AT
WWW.IC.UCI.EDU.
NO
PROFESSOR/TEACHER GRADUATE STUDENT RESEARCHER
PHYSICIAN OTHER: __________________________________________
DEGREES AWARDED (MARK ALL THAT APPLY): BACHELORS MASTERS PH.D M.D.
MAILING ADDRESS:
STREET ADDRESS:
CITY: PROVINCE: POSTAL CODE:
COUNTRY:
PHONE:
EMAIL:
SECTION TWO: VISA INFORMATION
ARE YOU CURRENTLY IN THE U.S.? YES NO
YES. I WILL BE LEAVING THE U.S. AND RETURNING BEFORE MY APPOINTMENT
YES. I AM REQUESTING A TRANSFER OF MY CURRENT J-1 STATUS
(COMPLETE SEVIS TRANSFER INFORMATION FOR J-1 SCHOLARS [SECTION THREE])
YES. I AM REQUESTING A CHANGE OF STATUS TO BE FILED IN THE U.S.
HAVE YOU APPLIED FOR A WAIVER TO THE 2-YEAR HOME RESIDENCY REQUIREMENT? YES NO
DURING YOUR LAST 24 MONTHS, HAVE YOU BEEN IN THE U.S. IN ANY VISA STATUS OTHER THAN TOURIST? YES NO
IF YOU MARKED YES ABOVE, PLEASE COMPLETE THIS PORTION.
IF YOU HAVE TRAVELLED TO THE U.S. DURING THE LAST 24 MONTHS, PLEASE PROVIDE DETAILS OF YOUR TRAVEL HISTORY BELOW.
[IF APPLICABLE]
VISA STATUS START AND END DATE OF STATUS LOCATION AND PURPOSE OF STAY
UCI International Center • Irvine, CA 92697-5255 • P: 949.824.7249 • F: 949.824.3090 • intl@uci.edu • www.ic.uci.edu
IC Office Use Only: Date Received: __________ Advisor’s Initials: ___________ | Revised On 11.15.2012[1]

UCI International Center
Form A
SECTION THREE: SCHOLARS TRANSFERRING TO UCI [TO BE COMPLETED BY ARO/RO AT SCHOLAR’S CURRENT INSTITUTION]
(COMPLETE ONLY IF YOU ARE TRANSFERRING YOUR J1 STATUS TO UCI):
SEVIS RELEASE DATE:
SCHOLAR’S SEVIS ID: N
CIP CODE ON CURRENT DS-2019:
START & END DATE OF PROGRAM:
FIELD OF STUDY/RESEARCH:
HAS THE SCHOLAR BEEN GRANTED OR APPLIED FOR A WAIVER TO THE 2-YEAR HOME RESIDENCY REQUIREMENT? YES NO
IS THE SCHOLAR IN VALID J1 STATUS: YES
NO
IF NO, EXPLAIN WHY NOT:
RO/ARO NAME AND TITLE [PLEASE PRINT]:
RO/ARO SIGNATURE:
INSTITUTION NAME:
INSTITUTION ADDRESS:
DATE:
PHONE NUMBER:
EMAIL ADDRESS:
• UC IRVINE J-1 PROGRAM: P-1-04818 •
EXCHANGE VISITORS AND THEIR DEPENDENTS WILL BE PERMITTED TO ENTER THE U.S. NO MORE THAN 30 DAYS BEFORE THE
START OF YOUR PROGRAM. U.S. GOVERNMENT REGULATIONS REQUIRE THAT ANYONE IN J-1 STATUS [OR WITH DEPENDENT J-2
STATUS] PURCAHSE ADEQUATE HEALTH INSURANCE AS DEFINED BY THE DEPARTMENT OF STATE. YOU WILL RECEIVE FURTHER
INFORMATION ABOUT THIS FROM THE UCI INTERNATIONAL CENTER.
ALL EXCHANGE VISITORS MUST REPORT TO THE UCI INTERNATIONAL CENTER UPON ARRIVAL IN THE U.S. IT IS MANDATORY THAT
YOU NOTIFY YOUR ACADEMIC DEPARTMENT AND THE UCI INTERNATIONAL CENTER SCHOLAR ADVISOR, AMY NETZKY,
ANETZKY@UCI.EDU, IMMEDIATELY IF THERE ARE ANY CHANGES TO YOUR PROGRAM.
SCHOLAR’S NAME [PRINT]:
SCHOLAR’S SIGNATURE:
DATE [MM/DD/YYYY]:
UCI International Center • Irvine, CA 92697-5255 • P: 949.824.7249 • F: 949.824.3090 • intl@uci.edu • www.ic.uci.edu
IC Office Use Only: Date Received: __________ Advisor’s Initials: ___________ | Revised On 11.15.2012[2]