ds-2019 extension request form j-1 exchange visitor program

University at BuffaloThe State University of New YorkOffice of International EducationImmigration ServicesDS-2019 EXTENSION REQUEST FORMJ-1 EXCHANGE VISITOR PROGRAM(Document must be filled out by the inviting faculty member, not the scholar)Please type or print clearly. Submit completed form and all other requireddocumentation to Immigration Services, 210 Talbert Hall, North Campus, Attention:MaryJean Zajac.Scholar's Name _______________________________________________________________Last/Family First MiddleMale ___ Female ___E-mail address _________________________Date of Birth ________________________Month/Day/YearPerson # ___________________________(if applicable)At UB, the scholar's primary activity will be: _______ Professor_______ Research Scholar_______ Short-term Scholar_______ SpecialistUB Department (e.g. Department of Chemistry)____________________________________________________________________________Department Address at UB________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Time Period for which the DS-2019 is Requested*Beginning Date**________________Month/Day/YearEnding Date ________________Month/Day/Year*While a Research Scholar/Professor may hold J-1 visa status for up to five years, it isrecommended that a DS-2019 be requested for only one year at a time to provide for annualverification of funding.210 Talbert Hall, Buffalo, NY 14260-1604Tel: (716) 645-2355 Fax: (716) 645-6197 E-mail: immgsvc@acsu.buffalo.edu

Accompanying Immediate Family Members (Spouse and/or Children)NAME:Last/Family, First/GivenRelationship to ScholarDate of Birth (Month/Day/Year)City and Country of Birth/CitizenshipNAME:Last/Family, First/GivenRelationship to ScholarDate of Birth (Month/Day/Year)City and Country of Birth/CitizenshipNAME:Last/Family, First/GivenRelationship to ScholarDate of Birth (Month/Day/Year)City and Country of Birth/CitizenshipNAME:Last/Family, Firsts/GivenRelationship to ScholarDate of Birth (Month/Day/Year)City and Country of Birth/CitizenshipThis DS-2019 Request Form MUST BE accompanied by:• a photocopy of the scholar's CV• a statement describing the research or teaching program the scholar willundertake, including the name of the scholar's immediate supervisor ordepartmental mentor and professional obligations, and a description of thefacilities and equipment (e.g. office/lab space, telephone, etc.) that will be madeavailable to the scholar.• a copy of the scholar's current DS-2019, and front and back of his/her I-94 card ifthe scholar is currently in the U.S. as aJ-1 scholar at another institution

Signatures of BOTH FACULTY AND CHAIR OR DEAN are required.Faculty Member Requesting DS-2019 FormName _____________________________ Title ___________________________Dept. Address ______________________ Phone _________________________Signature __________________________ E-mail _________________________Approval of Departmental Chair or DeanName _____________________________ Title ____________________________Departmental Address ________________ Phone__________________________Signature __________________________ E-mail __________________________Upon Completion of DS-2019 Form (check only one)_____ Immigration Services will mail DS-2019 Form by regular air mail to the scholarat:___________________________________________________________________________________________________________________________________________________________________________________ Immigration Services will mail DS-2019 Form by Express Mail (Please includeExpress Mail Service and account number)Express Mail Service: _________________________________________Account Number: _________________________________________________ Immigration Services will mail DS-2019 Form by campus mail to the facultymember requesting the DS-2019 so that the faculty member can mail it to thescholar.Faculty Member′s Name ______________________________________Campus Address _________________________________________________ Immigration Services will call _________________________ atPerson's Name_________________ for personal pick up.Phone NumberIf you have any questions, please call MaryJean Zajac, Immigration Services at 645-2355.02/07