Request for Issuance of Form ds-2019 Foreign Student and Scholar Services The University of Montana




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Request for Issuance of Form DS-2019


Foreign Student and Scholar Services

The University of Montana



Please note:


Professors and Research Scholars previously on a J-1 visa program may be subject to a 12 or 24 month bar before participating. Please contact Foreign Student and Scholar Services for further information.

Instructions:


Please provide the following information and return with the signed approvals for final processing to Barb Seekins, Foreign Student and Scholar Services, Lommasson Center 219,

University of Montana, Missoula, Montana 59812, 406-243-6183 or seekinsbh@mso.umt.edu.



1. Full Name (as it appears on passport):


Family name




First name




Middle name (optional)





2. Gender:


Female




Male



3. Date of Birth:



Month




Day




Year






4. City of Birth:







5. Country of Birth:







6. Country of Citizenship:







7. Country of Legal Permanent Residence:







8. Position in Home Country and Employer:





9. Reason for Issuance of DS-2019:


Begin a new program




Extension of Program




Transfer to a different program




Replace lost form




Permit visitor’s immediate family to enter U.S. separately






10. Period of Program:


Start

Month




Day




Year




End

Month




Day




Year






11. Category at UM:


Student




Professor




Research Scholar




Short-term Scholar




Specialist




Student Intern






12. Duties at UM:


(Write a one paragraph concise statement of the scholar’s project while at the University of Montana and its relationship to the University of Montana and the faculty counterparts’ research interests (attach CV and/or other information)





13. Source and Amount of Financial Support For the Entire Period (Use totals, not monthly figures; in addition to salary, specify value of any supplemental support for travel, housing, etc.):


Program Sponsor (UM):

$




U.S. Government Agencies:

$

Please list agency name:







International Organizations:

$

Name of Organization:







Bi-national Commission of the visitor’s country:

$




Exchange Visitor’s Government:

$




All Other Organizations:

$


Name of Organization:







Personal Funds:

$

14. List prior periods of stay in the U.S. in “J” classification for self and any dependent family members during the past twenty-four (24) months:


Start

Month




Day




Year



End


Month




Day




Year






15. If accompanied by dependents, please complete the following:


(copy and paste to create as many charts as necessary):

Name




Relationship




Citizenship




Date of birth




City and Country of Birth



16. Medical Insurance Requirements:


The department understands the exchange visitor and dependents will comply with J-1 medical insurance requirement. The department also understands that if the exchange visitor evades the medical insurance responsibility, the program is subject to termination.

Minimum coverage shall provide:



  • Medical benefits of at least $100,000 per accident or illness;

  • Repatriation of remains in the amount of $25,000;

  • Expenses associated with medical evacuation of exchange visitor to his/her home country in the amount of $50,000;

  • A deductible not to exceed $500 per accident or illness.

Scholar has been notified of health-insurance coverage requirements?

Yes




No




17. Exchange Visitor:


Email address




Phone number




Mailing address






18. Emergency Contact:


Name




Address




Email




Fax






19. University of Montana Program Information:


  1. Name of Primary UM Faculty/Staff Contact and contact information:

Name




Department of UM Faculty/Staff




Phone number




Email address







  1. Scholar will be provided with an office?

Yes




No







  1. Housing arrangements have been made?

Yes




No







  1. Scholar has been advised regarding Federal and State taxes and relevant tax treaties:

Yes




No







  1. Name of person who will meet and greet scholar at airport:

Name




Department of UM Faculty/Staff




Phone number




Email address



Approvals and Signatures




Contact person at UM:


Printed Name




Phone number




Email address




Signature & date






Person preparing request:


Printed Name




Phone number




Email address




Signature & date






Dept./Unit Head:


Printed Name




Phone number




Email address




Signature & date



Dean/Division Head:



Printed Name




Phone number




Email address




Signature & date






Director of International Programs:


Printed Name




Phone number




Email address




Signature & date






Return to:


Barb Seekins

Foreign Student & Scholar Services

Emma Lommasson Center 219

The University of Montana

Missoula, Montana 59812

Phone: (406) 243-6183



Fax: (406) 243-6115

E-mail: seekinsbh@mso.umt.edu


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