University of Nebraska Kearney

Request for Form DS-2019

Please submit this form electronically, and scan/email a copy of the personal information page of your Passport to: intnlserv@unk.edu.

Email Address  

PART I - SCHOLAR INFORMATION

1. Name of Student/Scholar:   

 Family Name   

Given Names (including middle name)  

2Male   Female     3.  Date of Birth     

4.  Place of Birth:  City       

Country   

5.  Country of Citizenship:      

6.  Country of Legal Permanent Residence:   

7.  Occupation:    

Employer:   

City of Employer (must be in country of permanent residence):   

8.  Has this Scholar held J-1 or J-2 immigration status at any U.S. institution in the past 12 months?  yes no  

If yes, give dates, location and purpose of most recent visit:   

(Bring copies of all previous DS-2019 forms and, if scholar is in the U.S., a copy of both sides of his/her Form I-94).  Please note:  a Scholar may not change J-1 caregory, e.g., student to scholar, in the U.S.

Has the Scholar previously visited UNK with the J-1 visa?  yes no  

If yes, give most recent dates:   

PART II-PROGRAM INFORMATION

10. Academic Field:   

11. Area of Specialization:   

12. Description of Scholar's proposed activities at UNK:  (Examples:  conduct research in atomic physics; teach courses in Italian; conduct three-day workshop in ecology; observe university administration)  

13. Dates of Visit at UNK: 

from  to  

Dates should include program dates ONLY.  They cannot include additional time for tourist or non-progam activities.   

A visiting Professor/Research Scholar on a J-1 visa may be documented to stay in the U.S. for a maximum of five years, although an extension of six months may be permitted for good cause to complete teaching or research responsibilities.  An individual is not eligible to begin a new program in the "Professor or Research Scholar" category if he/she has been physically present in the U.S. in J-1 or J-2 status for six months or more of the 12 month period immediately preceding the proposed starting date of the new exchange program.  However, a Professor/Research scholar currently in the U.S. in the J-1 visa classification status may transfer to a different Exchange Visitor (J-1) program. 

 PART III-FUNDING INFORMATION

14.  List all sources of support during visit.  Minimum support is $1200 per month plus $250 per month for accompanying spouse and $50 per month for each accompanying child.  Indicate total amount of funding in U.S. dollars for the entire visit;  please do not indicate monthly or annual salary.

yes no   Host Department at UNK:                  

Amount:   

REQUIRED EVEN IF NO FUNDING BY UNK:  UNK will will not   pay Visitor with U.S. Government funds obtained specifically for international exchange.  If yes, provide explanation or copies of relevant awards, contracts, or correspondence.

yes no   Other UNK Department(s) (provide letter from chair/director)

Amount:    

yes no   Scholar's government (identify ministry/agency)           

Amount:    

yes no   Other organizations(s) (identify)   

Amount:    

yes no   Personal funds (provide personal statement and bank statment or employer's letter regarding sabbatical pay, etc.)   

Amount:    

It is important that you provide documentation of any funding, normally a letter from the funding organization specifying the dates of the visit and specific amount of funding.  A letter from the Scholar is not sufficient documentation.

 PART IV-DEPENDENT INFORMATION

15. To be completed only if the Scholar intends to bring a spouse or child to the United States.  Be certain that the information provided is consistent with the individuals' passports.  If no dependents will be coming to the United States, leave blank.

Name (FAMILY/Given):    

Relationship to Scholar:  

Date of Birth (month/day/year):    

City of Birth:  

Country of Citizenship:  

Name (FAMILY/Given):    

Relationship to Scholar:  

Date of Birth (month/day/year):    

City of Birth:  

Country of Citizenship:  

Name (FAMILY/Given):    

Relationship to Scholar:  

Date of Birth (month/day/year):    

City of Birth:  

Country of Citizenship:  

NOTE:  Requirements for health insurance applies to J-2 dependents as well and verification of insurance will be required.

I understand that as a J-1 Exchange Visitor, I am required to attend a mandatory check-in program at the University of Nebraska at Kearney International Center and that I am required to maintain health insuracne that meets the requirmenets of the U.S. Exchange visitor program and the University of Nebraska at Kearney.  To the best of my knowledge, all of the information I have supplied here is accurate.

Signature:      

Date:  

FOR USE BY INTERNATIONAL STUDENT SERVICES STAFF

DS-2019 approved as (circle appropriate):

ISS Advisor Signature:  

Date:  

Welch Hall
2504 19th Avenue
Kearney, NE  68849
Email: intnlserv@unk.edu 
Phone: 308-865-8953
FAX: 308-865-8947