APPLICATION FOR A DS-2019 FORM
In order to issue a DS-2019, “Certificate of Eligibility for Exchange Visitor (J-1) Status,” the following information
is needed.
1.
NAME: Click here to enter text.
2.
CHECK ONE FOR EACH SET OF INFORMATION: Choose an item.
3.
BIRTH DATE: Click here to enter text.
4.
BIRTH PLACE: Click here to enter text.
5.
COUNTRY OF CITIZENSHIP: Click here to enter text.
6.
LEGAL PERMANENT RESIDENT IN: Click here to enter text.
7.
WHAT POSITION DOES THE VISITOR HOLD IN THEIR COUNTRY OF LEGAL PERMANENT RESIDENCE (E.G.,
PROFESSOR, UNDERGRADUATE STUDENT, RESEARCHER):
o
o
o
8.
Choose an item.
Position/Activity: Click here to enter text.
Institution/Company: Click here to enter text.
City and Country: Click here to enter text.
PERIOD OF STAY IN THE UNITED STATES: FROM:
TO:
Maximum anticipated stay (weeks, months, years): Click here to enter text.
9.
THE CATEGORY OF THIS VISITOR AT EAST CAROLINA UNIVERSITY WILL BE (SEE DEFINITIONS ON PAGE 5):
Student ☐
10.
Professor ☐
Research Scholar ☐
Short-Term Scholar ☐
Specialist ☐
DETAILED DESCRIPTION OF VISITOR’S PROGRAM AT ECU:
Major Field: Click here to enter text.
Minor Field: Click here to enter text.
Description: Click here to enter text.
11.
PRIMARY RESPONSIBILITY AT ECU WILL BE:
Teaching ☐
Research ☐
Other ☐ (Other, please explain): Click here to enter text.
12.
VISITOR’S SPECIFIC EDUCATIONAL FIELD: Click here to enter text.
13.
LIST DEGREES OR OTHER QUALIFICATIONS: Click here to enter text.
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FINANCIAL SUPPORT REQUIREMENTS FROM UNIVERSITY
If financial support is from any source other than East Carolina University, attach proof of support letter.
PROOF OF SUPPORT LETTERS MUST:

be on official University letterhead and include an official stamp of the University;

state the name, title, and show signature of a University official;

show proof of University support and agreement with the academic visit of the J-1 Exchange Visitor;

state the amount of financial support the individual J-1 Exchange Visitor will be receiving from their
University or government (this amount must be shown under Item #14, Financial Information, on the
Application for a Form DS-2019.)

show the name, title and position of the individual coming under the J-1 Exchange Visitor Program;

state whether or not medical insurance will be paid for by the University (copy of policy must be received in
English and submitted at Exchange Visitor’s check-in at International Affairs)

state whether or not stipend includes funds to purchase medical coverage on their own (English version of
policy must be submitted at Exchange Visitor’s check-in at the Office of International Affairs).
PERSONAL FUNDS - Financial documentation:
If the J-1 Exchange Visitor is not being paid by East Carolina University, the Exchange Visitor must furnish personal financial
documents to prove support for them and any dependents while in the US. Financial documents must be original bank
documents.
Dependent Coverage
Each J-1 Exchange Visitor must show $1000/month ($12,000/year) and an additional $4000/year for spousal support and
$2000/year for each dependent traveling with the Exchange Visitor.
14.
FINANCIAL SUPPORT: LIST EACH SOURCE AND AMOUNT (IN US DOLLARS) TO BE RECEIVED DURING
STAY.
$ Click here to enter text. ECU; Department: Click here to enter text.
Will any U.S. government funding be involved?
YES ☐
NO ☐
a. If yes, state the name of agency providing funds: Click here to enter text.
b. Was this government funding received specifically for this Exchange Visitor? YES ☐ NO
c. Was the funding received specifically designated for an Exchange Visitor program? YES ☐ NO ☐
15.
$ Click here to enter text.
U.S. Government Agency; Click here to enter text.
$ Click here to enter text.
International Organization; Click here to enter text.
$ Click here to enter text.
Exchange Visitor’s Government
$ Click here to enter text.
Personal Funds
$ Click here to enter text.
Other, please explain: Click here to enter text.
IF THE VISITOR HAS BEEN IN THE US PREVIOUSLY AS AN EXCHANGE VISITOR (J-1 VISA HOLDER), PLEASE
GIVE DETAILS OF PROGRAM: Click here to enter text.
Dates of program: Click here to enter a date. To: Click here to enter a date.
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16.
IF THE VISITOR WILL BE ACCOMPANIED BY A SPOUSE, CHILD, CHILDREN, PLEASE PROVIDE THE
FOLLOWING FOR EACH PERSON:
Last Name: Click here to enter text. First Name: Click here to enter text. Middle Name: Click here to enter
text.
Relationship to Visitor: Click here to enter text.
Place of Birth: Click here to enter text.
Date of Birth:
Present Nationality:
Last Name: Click here to enter text. First Name: Click here to enter text. Middle Name: Click here to enter
text.
Relationship to Visitor: Click here to enter text.
Place of Birth: Click here to enter text.
Date of Birth:
Present Nationality:
Last Name: Click here to enter text. First Name: Click here to enter text. Middle Name: Click here to enter
text.
Relationship to Visitor: Click here to enter text.
Place of Birth: Click here to enter text.
Date of Birth:
Present Nationality:
Last Name: Click here to enter text. First Name: Click here to enter text. Middle Name: Click here to enter
text.
Relationship to Visitor: Click here to enter text.
Place of Birth: Click here to enter text.
Date of Birth:
Present Nationality:
Last Name: Click here to enter text. First Name: Click here to enter text. Middle Name: Click here to enter
text.
Relationship to Visitor: Click here to enter text.
Place of Birth: Click here to enter text.
Date of Birth:
Present Nationality:
IF DEPENDENTS ARE ALREADY IN THE US, PROVIDE:
Passport number: Click here to enter text.
Passport Expiration Date: Click here to enter a date.
Country of Issuance: Click here to enter text.
17.
THIS REQUEST IS TO:
☐ invite visitor from another country
☐ transfer from another J-1 program
☐ change the status of an alien already in the US, to J-1 status
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IF THE EXCHANGE VISITOR IS CURRENTLY IN THE US, ATTACH PHOTOCOPIES OF THE FRONT AND BACK OF
FORM I-94, PICTURE PAGE OF PASSPORT AND PAGE SHOWING EXPIRATION DATE, AND A COPY OF THE DS2019
FORM.
18.
IF THE EXCHANGE VISITOR IS CURRENTLY IN THE US:
 present non-immigrant status is: Click here to enter text.
 sponsor is: Click here to enter text.
 present appointment: Click here to enter a date.
 date of entry to the U.S. in the current status: Click here to enter a date.
 permission to stay in the U.S. expires on: Click here to enter a date.
19.
Social Security Number: Click here to enter text.
TO BE COMPLETED BY ECU DEPARTMENT:
20.
Sponsoring department: Click here to enter text.
21.
The individual within the Exchange Visitor’s department who will be responsible for the visitor is:
a.
b.
c.
22.
Name: Click here to enter text.
Campus Phone Number: Click here to enter text.
Campus Address: Click here to enter text.
The person authorizing this appointment is:
a.
b.
Signature/Title:__________________________________________
DATE: Click here to enter a date.
Click here to enter text., Department Chair/Director
Department: Click here to enter text.
c.
Division: Click here to enter text.
d.
Signature/Title: __________________________________________
Click here to enter text., Dean
DATE: Click here to enter a date.
PLEASE RETURN THIS APPLICATION AT LEAST 2 MONTHS BEFORE EXCHANGE VISITOR’S ARRIVAL DATE TO ALLOW SUFFICIENT
TIME FOR PROCESSING.
TO:
Sandy Dumpor
Student/Scholar Services
International Affairs
East Carolina University
Greenville, NC 27858-4353
TEL: (252) 737-4378
FAX: (252) 328-4813
E-MAIL: dumpors@ecu.edu
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DEFINITIONS OF J-1 EXCHANGE VISITOR CATEGORIES
Student:
An individual who is studying in the United States pursuing a full course of study leading to or culminating in the award of a U.S.
degree from a post-secondary educational institution; or who is engaged full-time in a prescribed course of study of up to 24 months
duration conducted by a post-secondary accredited educational institution.
Professor: (Maximum stay is 5 years)
An individual primarily teaching, lecturing, observing, or consulting at a post-secondary accredited educational institution, museum,
library, or similar type institution. A professor may also conduct research, unless disallowed by the sponsor.
Research Scholar: (Maximum stay is 5 years)
An individual primarily conducting research, observing, or consulting in connection with a research project at research institutions,
corporate research facilities, museums, libraries, post-secondary accredited educational institutions, or similar types of institutions.
The research scholar may also teach or lecture, unless disallowed by the sponsor.
Short-Term Scholar: (Maximum stay is 6 months)
A professor, research scholar, or person with similar education or accomplishments coming to the United States on a short-term visit
for the purpose of lecturing, observing, consulting, training, or demonstrating special skills at research institutions, museums,
libraries, post-secondary accredited educational institutions, or similar type of institutions.
Specialist: (Maximum stay is 1 year)
An individual who is an expert in a field of specialized knowledge or skill coming to the United States for observing, consulting, or
demonstrating special skills. Exception: professors, research scholars, short-term scholars, and alien physicians in graduate medical
education or training.
PLEASE NOTE:
Sponsors are responsible for the effective administration of their exchange visitor programs.
Responsibilities include screening the prospective exchange visitors to ensure that they are eligible for program participation, the
program is suitable to the exchange visitor's background, needs, and experience; and the exchange visitor possesses sufficient
proficiency in the English language to participate in his or her program.
Sponsors shall monitor, through employees, officers, agents, or third parties, the exchange visitors participating in their programs.
(Definitions based on the Electronic Code of Federal Regulations, Title 22: Foreign Relations, PART 62, EXCHANGE VISITOR
PROGRAM, current as of July 9, 2012)
Revised SD: 7-12-2012
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