The purpose of this application is to:
- ( ) Begin a new program
- ( ) Extend a continuing program
- ( ) Transfer from another program
Please provide the information with requested documentation for the issuance of a DS 2019 form. This application, along with the requested documentation should be returned at least three months before the anticipated start date, in order to allow enough time for consular review.
Name of Faculty Sponsor:_____________________________________
Campus Phone #: ____________________________________________
Alternate Contact: ___________________________________________
If this application is for a scholar/student wishing to transfer from another institution, please ask the prospective exchange visitor if s/he has applied for a waiver of section 212e. __yes ___no
( ) Male ( ) Female Date of Birth ____/ ____/ ____
mm dd yyyy
Family Name First name Middle Name
City of Birth Country of Birth
Country of Citizenship Country of Legal Permanent Residence
Highest Degree Obtained: ____________ (Attach copy of degree)
Visitor’s occupation and place of employment in the home country:
If the visitor anticipates accompaniment by family members, please complete attached J-2 dependent information form.
Address and phone number where immigration documents should be sent:
Dates of Stay: From _________________To_______________________
Category of Visitor:
- ( ) student on proscribed course of study
- ( ) Professor
- ( ) Researcher
- ( ) Short-Term Scholar
A letter of offer/invitation to the visitor should be attached that provides a detailed description of activities and compensation. For students participating in exchange programs, please contact the study abroad office for information on application.
Indicate below the source(s) of funding and an estimate amount of money or in-kind contribution (rounded to the nearest dollar) the visitor will receive during the length of the program as will be indicated on the DS 2019:
1. ( ) UNC Pembroke (Includes positions funded by grants) $ _________
2. ( ) US Government Agency $ __________
3. ( ) International Organizations $ __________
4. ( ) Exchange Visitor’s Government $ __________
5. ( ) Binational Commission of the visitor’s country $ _________
6. ( ) All other organizations $ _________
7. ( ) Personal Funds $ _________
Please attach supporting documentation on funding amounts and sources
Please be advised that federal regulations governing the Exchange Visitor Program require that all exchange visitors must have health/accident insurance coverage that includes repatriation and medical evacuation coverage. Regulations do not require that UNCP pay for the insurance coverage, but must ensure that the exchange visitor and all accompanying dependents are properly covered for the duration of their stay. The Office of International Programs offers an insurance plan for purchase. Please contact International Student and Scholar Services for details.
Please indicate who will be responsible for health insurance coverage:
____________ sponsoring department _____________exchange visitor
Please note that the exchange visitor visa program cannot be used for activities primarily conducted apart from UNCP.