request form for ds-2019 (j

Active Minds Changing Lives
International Student & Scholar Services
516 High St. MS 9078-S
Bellingham, Washington 98225
Phone (360) 650-6517
Once this request form and the required supporting materials have been received, International Student &
Scholar Services (ISSS) will prepare the Certificate of Eligibility for Exchange Visitor Visa (J-1) Status within 10
business days. ISSS will send the certificate (Form DS-2019) to the hosting department for forwarding on to
the exchange visitor.
Hosting Department Information
Exchange Visitor duration of stay:
______/_______/_________ to ______/_______/_________
Department name: ________________________________________________
Describe the specific teaching or research activity at WWU:
Specific field of teaching or research activity at WWU: ______________________________________
Funding: Please provide documentation for ALL funding sources that will be used to support the exchange
visitor’s stay at WWU.
Documentation for funding from WWU may be included in the departmental letter of invitation.
Documentation from other sources should be provided on institutional letterhead with a
translation in English. If personal funds will be used to support the exchange visitor’s stay, a
personal bank statement can be provided to show proof of the availability of funds.
Funding must demonstrate a minimum of $1500 per month for the scholar, $600 per month for
the spouse, and $400 per month for each additional dependent.
Please note that the exchange visitor may be required to show proof of finances again at the
time of application for a U.S. entry visa at the U.S. consulate or at the U.S. port of entry.
Funding Source
Funding Amount
WWU (including grants from external sources)
______ Yes
U.S. government agency
______ Yes
Name of U.S. government agency:
International organizations
Name of international organization:
(See note above)
______ Yes
Government of home country
______ Yes
Binational Commission of home country
______ Yes
All other organizations providing support
______ Yes
Personal funds
______ Yes
Name of person extending invitation: __________________________________________________
Job title: _____________________________ E-mail: __________________________________
Department phone number: ___________________________________________________________
Contact information for person to whom Form DS-2019 should be forwarded:
Name of contact: _____________________________ E-mail: _________________________________
Department phone number: ________________________
Mailstop: ________________________
How would you like ISSS to handle Form DS-2019 when it is ready?
______ Send form by campus mail to contact person.
______ Contact person or someone will pick form up from ISSS.
Hosting Department Checklist
Please ensure that all of the following items are completed and attached BEFORE mailing this request to ISSS:
______ Completed DS-2019 Request Form
______ Completed Exchange Vistior Information Form and all accompanying documents
______ ISSS DS-2019 visa fee
______ Copy of departmental letter of invitation to Exchange Visitior or copy of WWU contract
______ Copy of supporting documentation showing proof of finances (for all categories indicated)
Departmental Certification
_____ The Department understands that all additional materials required by the applicant and the sponsoring
department must be received by International Student & Scholar Services (ISSS) in order to complete this
_____ The Department understands that all Exchange Visitors and their accompanying dependents must be
covered under a health insurance policy that meets the minimum standard established by the Department of
State. We further understand that failure to comply with this health insurance requirement may result in
cancellation of the visitor's J-1 status.
_____ The Department understands that the Exchange Visitor is required to engage ONLY in the activities
described on this form, in the Department indicated on this form, and for the length of time indicated on this form.
The Department will immediately notify ISSS of any change in activity or duration of stay.
_____ The Department will notify ISSS if the scholar cannot arrive within 30 days of the start date provided on the
DS-2019 document.
_____ The Department will send the scholar to ISSS for check-in upon arrival.
Signature of Department Chair or Director: __________________________________ Date: _________
Please forward request form and accompanying documentation to:
Richard Bruce
International Student & Scholar Services
Miller Hall 212; MS 9078S
Phone: 360-650-6517
[email protected]