UCI International Center Form A

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]