Application for Exchange (J-1) Status

Application for Exchange Status

Center for International Education
PERSONAL INFORMATION
Name

First NameMiddle NameLast (Family) Name
Date of Birth

DayMonthYear
Gender
If you use a name other than your legal name, please share it.
(Preferred name)
Attach your passport photo page.

If your passport is in progress, please attach your national ID.
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City of Birth
Country of Birth
Country of Citizenship
Country of Legal Residence
CONTACT INFORMATION
Preferred Phone #

Country CodeArea CodePhone Number
Email
example@example.com
Permanent Home Address (e.g. home country address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mailing Address
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

EXCHANGE VISITOR'S PROSPECTIVE ACADEMIC ACTIVITY
Visitor Category:
*If you are applying for EXCHANGE STUDENT status, please upload a copy of your transcripts, translated into English.

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*If you are applying for Professor or Research Scholar status, please upload a proposal describing your teaching or research plans.

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Begin Date

MonthDayYear
Home Institution (the university you are from)
End Date

MonthDayYear
Major/Field of study
Have you held a U.S. visa before?
If yes, please specify type
Please detail the purpose of your previous visa status.

DEPENDENT INFORMATION

Exchange visitor's non-U.S. citizen spouse and children under the age of 21 are eligible to obtain their own immigration documents as dependents of the primary visa holder. (If you are coming alone, skip this section.)
Will your family members accompany you to the U.S.?
Dependent #1
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Relationship to You
E-mail
example@example.com
City of Birth
Country of Birth
Country of Citizenship
Country of Legal Residence
Dependent #2
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Relationship to You
E-mail
example@example.com
City of Birth
Country of Birth
Country of Citizenship
Country of Legal Residence
Dependent #3
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Relationship to You
E-mail
example@example.com
City of Birth
Country of Birth
Country of Citizenship
Country of Legal Residence

NOTICE OF EXCHANGE VISITOR INSURANCE REQUIREMENT
The United States Department of State requires health, accident, repatriation, and medical evacuation insurance for participation in the Exchange Visitor Program. Nazareth College (the sponsor) must require each exchange visitor to have current insurance that covers the exchange visitor (and accompanying dependents) during the period of time that the exchange visitor participates in the sponsor's exchange visitor program.

The Department of State has established minimum requirements for insurance that are designed to protect the exchange visitor and their family. Minimum insurance coverage shall provide:

1. Medical benefits of at least $100,000 per accident or illness;

2. Repatriation of remains in the amount of $25,000;

3. Expenses associated with medical evacuation of the exchange visitor to their home country in the amount of $50,000; and

4. A deductible not to exceed $500 per accident or illness.
DECLARATION
Applicant Signature
** All visa holders must report to the Center for International Education as soon as possible upon their arrival to the United States. Please bring your passport, visa, and DS-2019.
Should be Empty:

Application for Exchange Status