REQUEST FOR (DS-2019) CERTIFICATE OF ELIGIBILITY
FOR EXCHANGE VISITOR (J-1 STUDENT) STATUS
New Jersey Institute of Technology
Office of International Students and Faculty
Fenster Hall Suite140
University Heights
Newark, NJ 07102
Tel: (973) 596-2451/Fax: (973) 596-5450
Please complete ALL sections, attach required documents and mail or fax to the address or telephone number listed above
A. STUDENT INFORMATION (All sections of this form must be complete)
1. ______gender: M / F
(family name) (first name) (middle name)
2. Date of Birth ______in ______
(mo/dy/yr) (city) (country)
3. E-mail address ______
4. Country of Citizenship ______
Country of legal permanent residence ______
5. Permanent legal address and telephone number in Home country
______
______
6. Current school of attendance:______
In ______
(city/country)
Degree you are pursuing at the above institution: ______
(BS/MS/PhD)
Major and/or specialization ______
7. Have you previously visited the U.S.? ____Yes ____No. If yes, when, and on what visa
type?______(attach photocopies of all supporting documents i.e. visa, passport incl. all notated pages)
8. ______Check mark here if student is currently attending NJIT and does not intend to depart the U.S. prior
to beginning a new program at NJIT. If checked:
a. ) What is the students current visa status? (e.g. B-2, F-1, etc.) ______
b. ) Please attach a photocopy of the student’s (and accompanying family member’s) I-94 card
(front and back).
9. _____Single _____ Married. If married, will spouse and/or children accompany student on J-2 status
______yes ______no
B. MAILING OF DS-2019 TO STUDENT
Please provide the mailing address and telephone number
______
______
C. AFFILIATION WITH NJIT
1. This is a ______new request ______extension
2. Length of required period of exchange with NJIT
To begin ______To terminate ______
(mo/dy/yr) (mo/day/yr)
D. FINANCIAL SUPPORT FROM ALL SOURCES WHILE AT NJIT
a. You must show a minimum of $1,500 per month for living expenses
Please provide a copy of your official bank statement or the statement of your parents. If you are receiving governmental funding please provide a statement including the amount of support awarded
b. Attach English translation of current supporting documents converted in U.S. dollars
Check mark below all appropriate means of support and indicate amounts:
Source Amount Per (wk/mth/yr)
_____ NJIT Funding U.S.$ ______per ______
_____ U.S. Government Agency U.S.$ ______per ______
Name: ______
_____ The Exchange Visitor’s Government U.S.$______per ______
_____ Other organization providing support U.S.$ ______per ______
Name: ______
_____Personal or Family support U.S.$ ______per______
j-1 student visitor information 05/07