J-1 Form (Health Sciences)

For Wake Forest Health Sciences

If you have any questions about this form or the J-1 Visitor program, please contact OfficeofIntlServices@wakehealth.edu.

Please fill out the following form accurately and completely.

NOTE: ALL FINANCIAL INFORMATION MUST BE GATHERED BEFORE FILLING OUT THIS FORM. YOUR DS2019 CANNOT BE PROCESSED WITHOUT NUMERICAL FINANCIAL INFORMATION.

Passport Information

Please email a copy of your passport data page to OfficeofIntlServices@wakehealth.edu

Family Name/Surname(Required)

Please input all names listed in the “Surname” field of your passport, exactly as they are written in your passport.

First Name/Given Name(Required)

Please input all names listed in the “Given Name(s)” field of your passport, exactly as they are listed.

Gender(Required)

Female

Male

Other

Current Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Permanent Foreign Address (if different from above)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Phone(Required)

Date of birth(Required)

City of birth(Required)

Country of birth(Required)

Country of permanent residency(Required)

Country of citizenship(Required)

Current or last employment in your home country (i.e. national government, local government, nonprofit, private industry, etc.)(Required)

If you selected Goverment Employee, can you be more specific?

Place of Employment/Study in Home Country (Comany or Institution)(Required)

Estimated start date of J-1 program(Required)

Estimated end date of J-1 program(Required)

J-1 category for your activity at Health Sciences/Bowman Gray Campus(Required)

Explanation of various J-1 categories:
1) Student Masters: Exchange visitor who will enrolled on a full-time basis in Health Sciences/Bowman Gray Campus M.S. program. (Maximum time: No set time; exchange visitor allowed to remain in U.S. until degree is obtained)
2) Student Doctorate: Exchange visitor who will be enrolled on a full-time basis in Health Sciences/Bowman Gray Campus Ph.D. program. (Maximum time: No set time; exchange visitor allowed to remain in U.S. until degree is obtained)
3) Research Scholar: Exchange visitor coming to Health Sciences/Bowman Gray Campus to conduct research, learn new techniques, etc. whose program will last for longer than six months. (Maximum time: Five years)
4) Short-term Scholar: Exchange visitor coming to Health Sciences/Bowman Gray Campus to conduct research, observe, learn new techniques, etc. whose program will not last longer than six months. (Maximum time: Six months)
Important: Please be aware of the fact that a short-term scholar program cannot be extended beyond six months; if you feel that there is even a slight chance that your program will go beyond six months, please select the “research scholar” category.

Department at WFU Health Sciences/Bowman Gray Campus that has agreed to sponsor you for your J-1 program(Required)

Name of contact person in sponsoring department(Required)

Please provide a brief description/summary of the research activities you will be conducting at Health Sciences/Bowman Gray Campus(Required)

English Proficiency

I have demonstrated my proficiency in English…(Required)

Please email appropriate documentation evidencing proficiency in English to OfficeofIntlServices@wakehealth.edu

Funding Information

Note: It is necessary that you provide a monetary amount for the funding information of your program. Please be sure to inquire with WFU Health Sciences/Bowman Gray Campus and/or other organizations to find out what types of financial support you will have available to you prior to filling out this form. If you will not be receiving financial support from WFU or an external organization, please list $1500.00/month and state you will be funding yourself under “Names of Organizations other than Health Sciences/Bowman Gray Campus who will provide funding”

This amount can be an estimate. Please list in U.S. dollar ($)

Note: It It will not be possible to process the DS-2019 form without an estimate of the amount of finances that you will be receiving either from Wake Forest or an external organization.

Total amount of financial funding/benefits provided by Wake Forest Health Sciences/Bowman Gray Campus(Required)

(salary, food, housing, scholarship, etc. – MUST BE NUMERICAL AMOUNTS, enter 0 if you will not be receiving any money from WFUHS)

Financial support coming from other source(s) – Numerical Amount(Required)

Email proof of funding to OfficeofIntlServices@wakehealth.edu.

Funding provided by outside organizations – i.e. NOT WFU Health Sciences/Bowman Gray Campus – MUST BE NUMERICAL AMOUNTS

If you will be funding yourself (or will be funded by family), please list at least $1500.00/month and list “personal savings” or “family savings” in field below.

Name(s) of organization(s), other than Health Sciences/Bowman Gray Campus, who will provide funding

Please list “personal savings” or “family savings” if you will not be funded by an external organization.

Additional information/comments

Visa Information

If currently in the U.S., what is your immigration status?

NOTE: If currently in J-1 Status and transferring to WFUS, please also complete J-1 Transfer-In Form

Expiration Date (Month/Day/Year)

Within the past 24 months, have you been physically present in the U.S. in either the J-1 or J-2 category as a professor or research scholar (does not apply to the short-term scholar category) for a period of 6 months or longer?(Required)

Yes

If on a J-1 VISA now or in the last 24 months, please indicate your category

Email Previous DS-2019s to OfficeofIntlServices@wakehealth.edu

Start date of J-1 Status (Month/ Day/ Year)

End date of J-1 Status (Month/ Day/ Year)

Program Sponsor (name/program number found on line 2 of DS-2019)

If in J visa status, have you applied for a waiver of 212(e), the Two-Year Home Residency Requirement?

Yes

If you have applied for waiver of the 212(e), has it been approved?

Yes

Email a copy of the waiver to OfficeofIntlServices@wakehealth.edu

Addtional Information about previous Visa Status(es)

Dependent Information

How many dependents will accompany you?(Required)

If dependents will accompany you, please provide the following information for each.

Dependent 1 family name

Dependent 1 given name(s)

Dependent 1 date of birth

Dependent 1 city of birth

Dependent 1 country of birth

Dependent 1 country of citizenship

Dependent 1 relationship

Dependent 2 family name

Dependent 2 given name(s)

Dependent 2 date of birth

Dependent 2 city of birth

Dependent 2 country of birth

Dependent 2 country of citizenship

Dependent 2 relationship

Dependent 3 family name

Dependent 3 given name(s)

Dependent 3 date of birth

Dependent 3 city of birth

Dependent 3 country of birth

Dependent 3 country of citizenship

Dependent 3 relationship

Dependent 4 family name

Dependent 4 given name(s)

Dependent 4 date of birth

Dependent 4 city of birth

Dependent 4 country of birth

Dependent 4 country of citizenship

Dependent 4 relationship

Dependent 5 family name

Dependent 5 given name(s)

Dependent 5 date of birth

Dependent 5 city of birth

Dependent 5 country of birth

Dependent 5 country of citizenship

Dependent 5 relationship

Untitled

Name

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Center for Immigration Services and Support

J-1 Form (Health Sciences)

For Wake Forest Health Sciences