Maine Medical Center Research Institute
81 Research Drive
Scarborough, ME 04074-7205
Tel: (207) 396-8238, Fax: (207) 396-8185
IMMIGRATION AND ARRIVAL FORM
(For use by the Office of International Programs)
Please fill out information for numbers 1-3
1. YOUR PERSONAL DATA
NAME: ______
(Family/Last) (Given/First) (Middle)
DATE OF BIRTH (month/day/year): ______
TELEPHONE NUMBER (best number to reach you): ______
INTERNATIONAL MAILING ADDRESS:______
CONSULATE FROM WHICH YOU PLAN TO OBTAIN YOUR VISA:______
PLACE OF BIRTH: ______
(City/Country)
COUNTRY OF CITIZENSHIP: ______
COUNTRY OF PERMANENT RESIDENCE: ______
HOST OR SUPERVISOR’S NAME: ______
MEDICAL NEEDS, if any; I.E. DIABETES, ALERGIES: ______
______
EMERGENCY CONTACT NAME: ______RELATIONSHIP TO YOU: ______
EMERGENCY CONTACT PHONE NUMBER: ______
EMERGENCY CONTACT ADDRESS: ______
______
2. FAMILY MEMBERS (ACCOMPANING SPOUSE AND CHILDREN)
NAME (Last, First) (1): NAME (Last, First) (2):
DATE OF BIRTH (month/day/year): DATE OF BIRTH (month/day/year):
COUNTRY OF CITIZENSHIP: COUNTRY OF CITIZENSHIP:
RELATIONSHIP: RELATIONSHIP:
PLACE OF BIRTH: PLACE OF BIRTH:
PASSPORT NUMBER: PASSPORT NUMBER:
PASSPORT ISSUING COUNTRY: PASSPORT ISSUING COUNTRY:
EXPIRATION DATE OF PASSPORT: EXPIRATION DATE OF PASSPORT:
NAME (3): NAME (4):
DATE OF BIRTH (month/day/year): DATE OF BIRTH (month/day/year):
COUNTRY OF CITIZENSHIP: COUNTRY OF CITIZENSHIP:
RELATIONSHIP: RELATIONSHIP:
PLACE OF BIRTH: PLACE OF BIRTH:
PASSPORT NUMBER: PASSPORT NUMBER:
PASSPORT ISSUING COUNTRY: PASSPORT ISSUING COUNTRY:
EXPIRATION DATE OF PASSPORT:______EXPIRATION DATE OF PASSPORT:______
3. PASSPORT INFORMATION
PASSPORT NUMER: ______EXPIRATION DATE (month/day/year): ______
ISSUED BY (country of citizenship): ______
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VISA STAMP INFORMATION
(Stamp obtained at U.S. Consulate Abroad)
STAMP NUMBER (red number):______TYPE:______
DATE ISSUED (month/day/year):______EXPIRE DATE (month/day/year):______
PLACE ISSUED:______NUMBER OF ENTRIES:______
(city and country) (one, two, M=multiple etc.)
ANNOTATIONS:______(written on visa page)
I-94 (small white card stapled in passport) INFORMATION
DEPARTURE NUMBER (ADMISSION NUMBER-upper left corner):______
PORT OF ENTRY INTO THE UNITED STATES (city and state):______
DATE OF ENTRY:______ADMITTED AS:______
(month/day/year) (visa type)
EXPIRATION DATE OR DESIGNATION (date specific or "D/S"):______
("D/S" means duration of status)
FOR F-1, J-1 and H-1 VISA HOLDERS
WHAT WAS YOUR INITIAL (FIRST TIME) DATE OF ENTRY
IN YOUR CURRENT IMMIGRATION VISA CATEGORY:______
IF H-1, WHAT IS THE EAC NUMBER OF YOUR APPLICATION:______
IF F-1, WHAT IS THE ADMISSION NUMBER ON YOUR 1-20 I.D. COPY:______
IF J-1, SUBJECT TO 2-YEAR HOME RESIDENCY? (yes/no):______(see "Annotations" on visa stamp)
IF J-1, PROGRAM SPONSOR:______
(Part 2 of DS-2019)
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PRINT NAME: ______
SIGNATURE:______DATE:______
Please return completed form to:
Office of International Programs (OIP)
Maine Medical Center Research Institute
81 Research Drive, Scarborough, ME 04074
Fax to: (207) 396-8185 or email to: