REQUEST FOR DS-2019 FORM "Certificate of Eligibility for

REQUEST FOR DS-2019 FORM
"Certificate of Eligibility for
Exchange Visitor (J-1) Status"
Please type or print legibly
Personal Information
Name (as it appears in your passport):
______________________________
Family Name
____________________
First Name
______________________ ( ) Male
Middle Name
( ) Female
Date of Birth: ________________________________ Place of Birth: ______________________________________________
US format: Month – Day – Year
City, State or Province
Country
Country of Citizenship: _________________________ Country of Legal Permanent Residence: ________________________
Highest Degree Earned: ________________________ Institution: ________________________________________________
Current or most recently held position in country of legal permanent residence (i.e., graduate student, professor, researcher,
etc.): ________________________________________________ Institution: ________________________________________
Type of Institution:
( ) Government: _____ Central _____ State/Province/Regional _____ City/Town
( ) University/College
( ) Private Company
Purpose of Visit
( ) Course Attendee: Course Name:____________________ Status: (student, faculty, TA, etc.) _______________________
( ) Research Award Recipient: Research Area (neurobiology, physiology, etc.): ____________________________________
( ) Employee: MBL Department: __________________________________________________________________________
( ) Other (please describe): ______________________________________________________________________________
Arrival Date: ________________________________________ Departure Date: _____________________________________
If you are a student in a course, these dates must coincide with the dates of your course; if you are a faculty/lecturer/teaching
assistant in a course, these dates must coincide with the dates of your MBL housing request/assignment.
J Exchange Program History
List the most recent visit to the U.S. as a J-1 Exchange Visitor (if any): From_ ______________________________________
Month, Day, Year
to __________________________ Category (Short-term Scholar, Research Scholar, Student) _________________________
Month, Day, Year
Shipping Information
Shipping address (DS-2019 will be delivered to you by courier so this CANNOT be a Post Office Box address):
Institution (if applicable): _________________________________________________________________________________
Address: _____________________________________________________________________________________________
Address: _____________________________________________________________________________________________
City: ______________________________________________ State/Province: ______________________________________
Country: ___________________________________________ Postal Code: ________________________________________
Phone: ___________________________ Fax: ________________________ E-mail: __________________________________
Form revised 1/25/13
Page 1 of 3
Family Information
If you want your spouse and children (under age 21) to join you as J-2 dependents, complete the following section:

Spouse (wife or husband) (
) will accompany me (
) will arrive later (expected date: __________________________ )
Name: _____________________________________________________________________________ ( ) Male
Surname or Family Name
First Name
Middle Name
( ) Female
Date of Birth: _____________________________________ Place of Birth: _________________________________________
Month, Day, Year
City, State or Province Country
Country of Citizenship: ______________________________ Country of Legal Permanent Residence: ___________________

Child
( ) will accompany me
( ) will arrive later (expected date: _______________________________________ )
Name: _____________________________________________________________________________ ( ) Male
Surname or Family Name
First Name
Middle Name
( ) Female
Date of Birth: _____________________________________ Place of Birth: _________________________________________
Month, Day, Year
City, State or Province Country
Country of Citizenship: ______________________________ Country of Legal Permanent Residence: ___________________

Child
( ) will accompany me
( ) will arrive later (expected date: _______________________________________ )
Name: _____________________________________________________________________________ ( ) Male
Surname or Family Name
First Name
Middle Name
( ) Female
Date of Birth: _____________________________________ Place of Birth: _________________________________________
Month, Day, Year
City, State or Province Country
Country of Citizenship: ______________________________ Country of Legal Permanent Residence: ___________________
Note: If you have more than two children, you may duplicate this page.
Funding Information
J-1 visa holders are required by the US government to have the minimum amount of funds necessary to cover living expenses
while in the United States. In Woods Hole, this amount is at least US$61/day (or US$1,891/ month) for the J-1 visa holder,
plus US$26/day (or US$806/ month) for a spouse, and US$16/day (or US$496/ month) for each child. Please complete the
following section using the amount of days/months between your arrival and departure dates as listed on page 1 to determine
the amount of funds required for your stay. (Note: MBL Course Faculty/Lecturers/TAs do not need to complete this section.)
MBL Award or Salary ................................................................................................................. $___________
Less Tuition (if Student) or Lab Rental (if Research Award Recipient) ................................... - $___________
Less Minimum Living Expenses:
_____ days or months at MBL x $61/day or $1,891/month = $_______ for J-1 Visa Holder
_____ days or months at MBL x $26/day or $ 806/month = $_______ for Spouse
_____ days or months at MBL x _______ number of children
x $16/day or $ 496/month
= $_______ for Children
Subtotal of Living Expenses .............- $___________
TOTAL................................................. $___________
If TOTAL is a negative number, you must indicate below the amount of funding in US$ and the name of the funding source
that will cover these funds. In addition, you must submit proof of these funds with your application (see page 3 for acceptable
forms of proof). A DS-2019 Form cannot be issued if these funding levels cannot be met and proof of funding is not received.
Type of Funds
Amount per (month, year, or course)
US Government Funds
$
per
International Organization
$
per
Scholar's Home Government
$
per
Binational Commission
$
per
Other
$
per
Scholar's Personal Funds
$
per
Form revised 1/25/13
Name of Funding Source
Page 2 of 3
MARINE BIOLOGICAL LABORATORY
Acceptable Proof of Funds:
Foreign Government, Foreign Employer, or Other Non-MBL Organizational Funding: If you will be funded by a Foreign
Government, Foreign Employer, or Other Non-MBL Organization, an official letter on letterhead from the funding source must
be submitted confirming the following: 1) total amount of funding provided to you (the exact amount and the type of currency
in which the amount is stated); 2) the dates during which the funding will be provided; and 3) the signature of the person in the
organization who is authorized to guarantee the funding.
Personal/Family Funds: If you will be funded by personal or family funds, you must provide bank statements or bank letters
showing savings sufficient to meet minimum funding requirements in US dollars. These documents must state a specific
amount of funds available to you. If the documents you submit are in a family member’s name, they must be accompanied by
a statement from that person confirming the following: 1) relation to you; 2) intent to sponsor your stay in the US; 3) amount
and currency; and 4) duration of support.
Note: All documents showing proof of funds not written in English must be accompanied by an English translation.
Facsimile or scanned copies can be provided, but official documents must also be sent by mail.
INSURANCE NOTIFICATION AND CLEARANCE FORM
The Exchange Visitor Program requires all program sponsors to notify their exchange visitors that they and their dependents
must have insurance coverage that meets the following minimum criteria:




Medical benefits of at least $50,000 per accident or illness
Repatriation of remains in the amount of $7,500
Expenses associated with the medical evacuation of the exchange visitor to his or her home country in the amount
of $10,000
A deductible not to exceed $500 per accident or illness
You must show proof of insurance within 30 days of your arrival at MBL and the coverage for the exchange visitor and
dependents must remain in effect for the duration of the exchange visitor’s association with the MBL.
Please sign the statement below: “I agree to maintain insurance coverage that meets the above limits as set by U.S. Dept.
of State for myself and my dependents for the full length of our stay in the United States. I understand that failure to do so
may result in the termination of my J-1 program.”
Signature: _________________________________________________ Date: ___________________________________
You must read and sign the following statement: “The information provided on this request form and on any attached
documents is true, correct, and complete to the best of my knowledge.”
Signature: _______________________________________________________ Date: _______________________________
Some Important Reminders:
--Do not forget to spell your name exactly as it appears on the passport.
--Do not forget to put your date of birth in order by month, day, and year.
--Do not forget to attach proof of funding sources and amounts if required.
Please return your request to:
Jane MacNeil, Foreign National Coordinator
Marine Biological Laboratory
7 MBL Street
Woods Hole, MA 02543-1015, USA
Telephone: 508-289-7378
Fax: 508-289-7118
E-mail: [email protected]
Form revised 1/25/13
Page 3 of 3