Request for Issuance of Form DS-2019 For Use by Departments at East Tennessee State University When an ETSU department has invited an international scholar(s) for a visit, the J-1 visa is often the most appropriate for the visitor. This form should be completed by the host department (not by the visitor), signed by the department head, and sent to: International Programs and Services, Box 70668. The Director will then issue a Form DS-2019 that the scholar should use to get a J-1 visa to enter the U.S. This request form should not be used for students. If you have any questions, please call the International Programs and Services at 439-7737. Part I – Department Information Host Department: Department Address: Street: City: State: Phone: Zip/Postal Code: Fax: Host Professor/Staff Member: Phone: E-mail: ----------------------------------------------------------------------------------------------------------------------------------------Part II – Scholar Information Name of Scholar Last: Male: Female: Place of Birth City: First: Middle: Date of Birth (mm/dd/yyyy): Country: Country of Citizenship: Country of Legal Permanent Residence: Occupation and Employer in Country of Permanent Residence Occupation: Employer: Highest Degree Received (check one) Ph.D. Other: If not Ph.D., give date and actual name of degree (not U.S. equivalent): See the English Language Proficiency Policy on the International Programs and Services Forms webpage under J-1 Scholars heading. How will the prospective visiting scholars document his or her English Proficiency level? ____TOEFL – scores must be submitted to ETSU electronically. ____Oral Proficiency Interview (OPI) test – if this is the option, please contact Dr. Martha Michieka January 2015 (Michieka@etsu.edu) to make an appointment for the interview via WebEx. Dr. Michieka will provide International Programs and Services with the OPI report. Has this scholar held J-1 immigration status in the past 12 months? Yes: No: If yes, give dates and locations of most recent visit: (If scholar is currently in the U.S., attach copies of all previous IAP-66 and DS-2019 forms.) Will the scholar be accompanied by spouse or children? Yes: No: If yes, give names, dates of birth, places of birth, and relationship to scholar on a separate page. Visitors Mailing Address: Street: City: State: Country: Zip/Postal Code: Telephone Number: Fax Number (if available): E-mail Address: Check One: International Programs and Services should mail DS-2019 by regular mail. Host Department will mail DS-2019: please call when ready for pick-up. Mail by Express Courier; charge to Host Department account number: ---------------------------------------------------------------------------------------------------------------------------------------Part III – Program Information Description of Scholar’s Proposed Program at ETSU (Examples: conduct research in theoretical physics; teach courses in Italian; conduct three-day workshop in ecology; observe university administration, etc.) Dates of visit at ETSU (mm/dd/yyyy) From To PLEASE NOTE: It is the responsibility of the visiting scholar’s faculty/staff host to notify International Programs and Services if the exchange visitor is not able to enter the United State by the program date noted above. The visitor’s SEVIS record MUST be promptly updated in such circumstances. An exchange visitor may not enter the United States after program beginning date has passed. If you have any questions, please call 9-7737. Proposed job title at ETSU, if applicable (J-1 Visa may not be used for tenure-track positions) Will scholar be employed by or visiting other U.S. institutions before or after ETSU visit? Yes: No: If yes, give details on a separate sheet or call the International Programs and Services office to discuss. (Visitor is permitted to live in U.S. for up to 30 days as travel after leaving ETSU without special January 2015 permission. Employment is permitted during this period.) Is there a possibility that the scholar will extend his/her stay beyond the dates given above? Yes: No: If yes, will scholar stay longer than six months? Yes: No: Or longer than three years? Yes: No: Explain: ----------------------------------------------------------------------------------------------------------------------------- ----------Part IV – Funding Information List all sources of support to scholar during visit. Please document all non-ETSU financial support. Source Host Department at ETSU Visitor’s Government (submit documentation) Personal funds Other – Specify: Amount Please Note: Exchange Visitors under the J-1 status are not eligible for any type of U.S. government aid such as food stamps, free health care, free school lunches, subsidized housing, etc. Acceptance of such aid is a violation of the J-1 regulations. ETSU Will or Will Not pay scholar with funds obtained specifically for this Scholar or for international exchange. If yes, provide explanation or copies of relevant contracts or correspondences (this does not apply to research funds). Facilities and services the department will provide for scholar (Examples: office, telephone, secretarial help, free housing, hotel accommodations paid for, etc.): _________________________________________________________________________________ Part V – Export Control Regulations An export occurs when a controlled physical item or controlled information is transmitted outside the United States borders or when a controlled physical item or controlled information is transmitted to a foreign person in the United States. The term “export” includes: (1) actual shipment of any controlled physical items; (2) the electronic or digital transmission of any controlled information; (3) any release or disclosure, including verbal disclosures and visual inspections, of any controlled information; or (4) actual use or application of controlled physical items or controlled information on behalf of or for the benefit of a foreign entity or person anywhere. Additional information is available Is there a possibility that the scholar will be involved in research activities which may have implications under federal export control regulations? Yes: No: _I do not know: _ If yes, review and approval from ETSU’s Regulatory Compliance Officer is mandatory. If you have any January 2015 question, please call the Office of Research and Sponsored Programs Administration at 439-6052. ----------------------------------------------------------------------------------------------------------------------------- ----------Part VI – Health Insurance Information Host Department Will or Will Not pay for health insurance for the visitor. Please Note: All J-1 visiting scholars and their dependents MUST have health insurance in accordance to the Please Note: Federal Regulations make health insurance coverage mandatory for all exchange visitors under the J-1 status throughout their stay in the United States. Approved by Host Department Head: Signature: Name: Date: January 2015