Loyola University
Chicago
Office for International Programs (OIP)
DS-2019
Request
To be completed by the hiring department
Certificate of Eligibility for J-1 Exchange Visitor (EV) Status
Please make sure all writing is legible. Please submit all required forms and supporting documents at least 2 months in advance of intended
starting date.
I.
Purpose of Request (check one)
1.
2.
3.
Begin a program at Loyola University Chicago; accompanied by ( ) immediate family members
Extend the on-going program at LUC, complete all but supervisor’s certification
Transfer from another institution’s program to LUC’s program
Exchange Visitor at LUC:
II.
First time
Current, IAP-66 expires
Previously at LUC, date
DS-2019 (check one)
Department will pick-up from OIA
OIP Express Mail to EV in his/her home country
(For IAP-66 or DS-2019 Extension EV must come to OIP to pickup)
(Please include pre-paid express mail envelope)
III.
Exchange Visitor (EV) Information
Male
Family Name
First
Middle
City of Birth
Country of Birth
Country of Citizenship
Country of Legal Permanent Residence
Female
Date of Birth
E-mail address
U.S. Social Security Number if Available
Highest Degree Earned
Position/job title in country of legal permanent residence
Institution is:
If Government:
Government
Central
Name of Home Country Institution where EV works/studies
Academic Community
Private Sector
State, Regional, or Provincial
Other
City or Town
EV Home Country Address:
(Number) (Street)
(City or Providence)
(Country)
(Country Code)
(Number) (Street)
(City)
(State)
(Zip Code)
U.S. Address, if applicable:
Accompanied by the following immediate family members (sufficient funds must be available----See V.)
Name (Family, First)
Relationship
Birth-date (mm/dd/yy)
City of Birth
Country of Birth
Country of Citizenship
(Attach a separate sheet for additional dependents)
IV.
Loyola Information
Proposed Dates of Visit for this DS-2019: From / /
To
/ /
mo/day/yr
mo/day/yr
Self-funded EV limited to one year initially, with the possibility of one year extensions, to a maximum of 3 years for research
scholars and professors.
Select Category:
Non-degree Student
(24 month maximum)
Research Scholar
(5 years maximum)
Short-term Scholar
(6 month maximum)
Professor
(5 years maximum)
*If program dates are greater than 6 months, the scholar will be categorized as a Research Scholar, making them subject to the 24 Month Bar at the end
of their program.
What appointment title will EV be given while at Loyola?
Hours per week to be involved in the Exchange Visitor (EV) activity
Briefly describe the primary activity to be performed at LUC. Basic area of research or teaching:
Form 1A
V.
Funding: Source(s) of and total financial support for EV for the period of proposed visit (section IV).
Attach proof of support for funding from sources B-G. Financial documents must be on institutional letterhead, not older than 6 months and
should specify amount and date of support. Translate documents, if not in English, and convert funding amount to U.S. dollars. Current minimum
expense amounts, per month, are $1222 for J-1; $460 for spouse; $320 for each child. Funding requirement amounts are subject to change.
Source:
Amount:
A) Salaried through:
LUC payroll
Stipend
Is LUC funding from any government agency?
No
Yes
If yes, is this funding specifically designed for international exchange?
$
No
Yes
per
year
month
If yes: Name of agency:
B) Direct from U.S. Government Agency (name):
$
C) From International Organization(s) (name):
$
D) Exchange Visitor’s Government
$
E) Bi-National Commission (name, e.g., Fulbright):
$
F) Other organization(s) (name):
$
G) Personal Funds
$
Total Funding (Add A through G)
$
*If funding is NOT from a Loyola University source, please attach photocopies of the letter of award, statement of salary continuation
and/or the EV’s personal bank statement to show that the department has verified sufficient funding for the visitor’s entire program.
VI. Health Insurance
Will the Exchange visitor be eligible for university insurance coverage?
No
Yes
If no, EV must purchase a private policy that meets Dept. of State requirements. Rates are subject to change without notice and are dependent on
the age of the visitor.
VII. Current Immigration Status of EV (Does not apply to extension requests)
Is Exchange Visitor presently in the U.S.?
No
Yes
If yes, in what status? (e.g. F-1, B-2, J-1, H-4, TH, etc.)
If yes, attach a copy of I-94 (front and back) and copies of all immigration documents, e.g. I-20, IAP-66, 1797, etc.
If in U.S. check one:
Individual intends to leave U.S. and reenter in J-1 status
Individual will remain in the U.S. an apply for program transfer to LUC through OIA
VIII. Other Information
Will EV be enrolled as a student at LUC during this period?
Will EV perform research/project at places/sites other that LUC?
If yes, please specify:
No
No
Yes
Yes
Will EV be in a tenured track position?
No
Yes
IX. Certification
I authorize sponsorship of the Exchange Visitor and certify that LUC funds ARE available to this individual as indicated above. In the case that
LUC is not providing health insurance, we have informed/will inform the EV of the insurance requirements. I understand that the EV will be
terminated if he/she engages in unauthorized employment and/or willfully fails to maintain the required health insurance coverage for him/herself
and all J-2 dependents. EV will meet with an advisor at the Office for International Affairs upon arrival to LUC.
Departmental Host Professor
Campus Address
Campus Phone #
___________________________________________________________
Signature of Departmental Chairperson
Name of Department
Date Signed
___________________________________________________________
Signature of Dean
Name of School
Date Signed
___________________________________________________________
Signature, Academic Affairs (Provost or designee)
Date Signed
(Note to Academic Affairs: Please return this form to the Departmental Contact Person listed above after signing.)
Form 1B
Revised 6/06
OIP
Supervisor’s Certification
(Use only for initial DS-2019 request)
DS-2019
Request
Exchange Visitor’s Name
INSTRUCTIONS: To be completed by the faculty member most closely associated with the Exchange Visitor.
1.
PROGRAM ELIGIBILITY
I have evaluated the academic and professional credentials of this prospective Exchange Visitor (EV), and
consider him/her to be qualified to participate in the proposed activities in the department.
Basic field of research:
Duties:
2.
ENGLISH PROFICENCY
I have determined that the prospective Exchange Visitor has sufficient English proficiency to enable him/her to
successfully carry out the activities described above and to have an enriching cross-cultural experience while at
LUC. The EV’s English language ability has been determined by the following (Check all that apply):
English is the EV’s first language
Previous interactions with the EV
Telephone conversations with the EV
Recommendation of objective 3rd party
Written communication
Visit will be no more than one month. English proficiency assessment is not required.
Other (explain):
3.
SPONSORSHIP
As a sponsor and supervisor of this prospective Exchange Visitor, I certify that the above is true and correct and
I understand that the EV’s J-1 program may be terminated if the EV:
A. Fails to participate in the proposed activities/duties
B. Engages in unauthorized employment, and/or
C. Willfully fails to maintain the required medical insurance coverage for himself/herself and for all J-2
dependent(s).
___________________________________________
Print Name of the Faculty Member
Signature of the Faculty Member
Campus Phone #
Department
Campus Address
Date
Please submit completed Form 1A & B, and Form 2 to:
Mary Theis
Office for International Programs (OIP)
Sullivan Center, Lake Shore Campus
(Phone Ext: 8-3899)
Form 2
revised 2/03