Application for Exchange (J-1) Status

Application for Exchange Status

Center for International Education
PERSONAL INFORMATION
Name *

First Name Middle Name Last Name
Date of Birth *

Day Month Year
Gender *

Male Female
Attach your passport photo page. *

If your passport is in progress, please attach your national ID.
Cancel of
City of Birth *
Country of Birth *
Country of Citizenship *
Country of Legal Residence *
CONTACT INFORMATION
Preferred Phone # *
Email *
example@example.com
Permanent Home Address (e.g. overseas address) *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Mailing Address

Same as above Add a different mailing address
Mailing Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

EXCHANGE VISITOR'S PROSPECTIVE ACADEMIC ACTIVITY
Visitor Category: *

Professor* Research Scholar* Student Bachelor's* Student Master's Student Doctorate Student Non-Degree*
*If you are applying for EXCHANGE STUDENT status, please upload a copy of your transcripts, translated into English.

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

Cancel of
Begin Date *

Month Day Year
Home Institution (the university you are from) *
End Date *

Month Day Year
Major/Field *
Have you held a U.S. visa before? *

Yes No
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.
Will your family members accompany you to the U.S.? *

Yes No
Dependent #1
Full Name

First Name Middle Name Last Name
Date of Birth

Month Day Year
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 Name Middle Name Last Name
Date of Birth

Month Day Year
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 Name Middle Name Last Name
Date of Birth

Month Day Year
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 *

I hereby certify that the information on this application is both complete and accurate. I understand that falsifying any part of this application may result in my being refused admission or being required to withdraw from the college. I also certify that I am aware of the health insurance requirements and will abide by these requirements.
** 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

PERSONAL INFORMATION

CONTACT INFORMATION

EXCHANGE VISITOR'S PROSPECTIVE ACADEMIC ACTIVITY

DEPENDENT INFORMATION

ENGLISH PROFICIENCY

U.S. IMMIGRATION INFORMATION

FINANCIAL SUPPORT

NOTICE OF EXCHANGE VISITOR INSURANCE REQUIREMENT

DECLARATION