International Student and
Scholar Services
JMAC 6, Suite 23, MSC 5731
Tel: 568-6119
Fax: 568-8080
isss@jmu.edu
Background Form for International Visitors/Scholars
NOTE: Please answer every item – all information is required by the U.S. government for completion of certain
immigration documents. Please type fill-in text fields, print and then sign.
VISITOR
Last Name:
First Name:
Date of Birth: Month: January Day:
Middle Name:
Year:
Male
Place of Birth: City:
Occupation at home:
Country:
Exchange Visitor Category: Student Intern
Country of Citizenship:
Female
Major:
Country of Legal Permanent Resident:
Address in home country:
Address in the U.S., if applicable:
Phone number:
Email address:
Other than vacations, if you had any previous stay in the United States please complete the following:
Visa Type: F-1
J-1
Other
If other, please specify:
Dates of Previous stays in the US: January Day:
Year:
until January Day:
Year:
DEPENDENTS (if any) (If more than 1 dependent, please indicate all on the back of this page.)
Last Name:
First Name:
Date of Birth: Month: January Day:
Country of Citizenship:
Middle Name:
Year:
Male
Place of Birth: City:
Female
Country:
Country of Legal Permanent Resident:
SPONSOR, PROGRAM AND DURATION
Name of the JMU Sponsoring Department:
JMU Sponsor Name
Phone Number:
Email Address:
Brief Description of Scholar/Visitor’s Proposed Activity while in the US:
PLEASE NOTE: J-1 SCHOLARS ARE ALLOWED TO ENTER THE USA 30 DAYS BEFORE THE PROGRAM START DATE BUT THAT ARRIVING
AFTER THE PROGRAM START DATE MAY BE DENIED ENTRY. PLEASE PLAN THE PROGRAM START DATE ACCORDINGLY.
Program Dates: January Day:
Year:
until January Day:
Year:
FINANCIAL SUPPORT
JMU’s total financial contribution to the visitor/scholar (include reimbursement of expenses and/or salary): $
This program has not received funding from any U.S. Government Agencies.
This program has received funding from the following U.S. Government Agencies:
If so, name agency(s):
Amount: $
Other sources of funding: Personal Funds: $
Binational Commission of Exchange Visitor’s Government: $
Exchange Visitor’s Government: $
All other organizations: $
Please name:
Signature of VP, Dean or Department Head__________________________________________Date: __________________________________
Return completed form to JMU’s Office of International Student and Scholar Services (MSC 5731) at least 3Pl months prior to the visitor’s
anticipated start date.