I attended/will attend: (check one):
Orientation on the Main Campus
Orientation at the UC Davis Medical Center
Orientation Online
SCHOLAR PERSONAL DATA SHEET
CURRENT INFORMATION
Name:
Male
Family (Last)
Country of citizenship:
Is family here now?
Spouse’s name:
Yes
First
Date of birth:
If “No,” will family join you later?
No
Female
Middle
Family (Last)
mm/dd/yy
Yes
First
No
Middle
Children under 21 years of age who accompanied you or will be visiting you (names & ages)
Family (Last):
First:
Middle:
Age:
Current address in California
Street Number
Street Name
Phone Number with Area Code
Personal Email:
UCD Email :
Apartment Number
Home or
City
Cell
Postal Zip Code
Office/Lab Phone
HOME COUNTRY ADDRESS
Street Line 1:
Street Line 2:
State/Province:
City:
Postal Code:
Country:
PERSON TO BE NOTIFIED IN CASE OF AN EMERGENCY
Name:
Address:
Phone number:
Relationship:
E-mail address:
2 YEAR HOME RESIDENCY REQUIREMENT/ 212 (e)
Please check your J-visa stamp and DS 2019  Are you subject to 212 (e)?
Yes
No
If “Yes”, please indicate what it is based on (listed on DS 2019, lower left corner):
Government Financing
and/or Exchange Visitor Skills List
As the J Exchange Visitor Program Sponsor, UC Davis does not assist with 212 (e) waiver applications. Requesting a
waiver is the J Exchange Visitor’s responsibility. However, it is strongly recommended that J Exchange Visitors notify SISS
of waiver plans as it can affect your J-program, especially extension requests.
HEALTH INSURANCE
Do you currently have health insurance?
Yes
No
If “Yes,” name of provider:
I understand that I am responsible for maintaining health insurance coverage throughout my stay in the U.S. If I do not
currently have insurance, I will purchase insurance immediately. Please see our website for more information about
insurance options: http://siss.ucdavis.edu/scholars_depts/j_visa/j-insurance.html .
Signature of scholar
Date
To view an orientation slideshow, visit our orientation webpage: http://siss.ucdavis.edu/scholars_depts/j_visa/j_new.html
Rev May 2014