APPLICANT REQUEST
For the DS-2019 Certificate of Eligibility for J-1 Status
FAMILY NAME (SURNAME)
FIRST NAME
MIDDLE NAME
DATE OF BIRTH (MM/DD/YYYY)
Month:
Day:
Year:
CITY OF BIRTH
COUNTRY OF BIRTH
COUNTRY OF CITIZENSHIP
COUNTRY OF PERMANENT RESIDENCE
E-MAIL ADDRESS
GENDER/SEX
MARITAL STATUS
ARE YOU A MEDICAL DOCTOR (MD)?
MOST RECENT JOB OR POSITION
 Male
Female
 Single
 Married
 Yes
 No
(STUDENT, DOCTOR, RESEARCHER, PROFESSOR, ETC.)
INSTITUTION/COMPANY NAME
(OF MOST RECENT POSITION OR JOB)
Street: ________________________________________________________
MAILING ADDRESS IN
COUNTRY OF PERMANENT RESIDENCE
(NON-U.S. ADDRESS)
City: ___________________________ State/Province: __________________
Postal Code: __________________ Country: __________________________
ATTACH THE FOLLOWING DOCUMENTS TO
THIS APPLICATION
 CLEAR copy of passport biographical information page
 Proof of financial support if not funded by Jefferson (e.g. bank statement,
financial support letter from home country institution or government,
scholarship letter, etc.)
 Copy of resume or curriculum vitae
 If J-1 Transfer or status change: CLEAR copies of previous DS-2019’s,
visas in passport and I-94 record
J-1 ATTESTATION OF ENGLISH PROFICIENCY
The U.S. Department of State requires sponsors of J-1 exchange visitors to demonstrate proof that the J candidate has "sufficient
proficiency in the English language, as determined by an objective measurement of English language proficiency, successfully to
participate in his or her program and to function on a day-to-day basis." [22 CFR 62.11(a)(2)].
I confirm that I have demonstrated sufficient English proficiency with my sponsoring Jefferson department in one or more of
the following ways (as deemed to be appropriate by the Department of State and Office of International Affairs):



Completed an interview conducted in English with my Jefferson department; OR
Provided a minimum TOEFL or IELTS score taken within the past 5 years (TOEFL = 79 or IELTS = 6.5); OR
Provided proof of advanced level English proficiency from a recognized English language institution OR copy of transcripts
from a university in an English-speaking country
I certify that the information I am providing with this form is complete and true to the best of my knowledge.
Signature _________________________________________________________ Date __________________________________
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rev.12.2014ek
Department Section
Applicant Section
Applicant Dependents Section
www.jefferson.edu/international_affairs
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