DS-2019 Request Form

International Student Services (ISS)
Phone: (408) 551-7037
Fax: (408) 554-2709
Email: ISS@scu.edu
______________________________________________________________________
DS2019 REQUEST FORM FOR J-1 STUDENTS
______________________________________________________________________________
Form Instructions and Documents to be Included:
• All fields MUST be complete in order for ISS to process the DS-2019. If a question does not
apply, please write N/A in the appropriate field.
• Passport -attach a photocopy of identity/biographical page of passport with this form.
• Appropriate Campus Approval -copy of acceptance/invitation letter from department host.
• Proof of Funding -both visitor and host department must ascertain the J-1’s financial capability.
Verification of funding must be submitted with this form.
• Previous DS-2019 –if visitor has been in J status in the past 2 years, include a copy of DS-2019.
• Health Insurance – required of all J-1 visitors. Please complete Insurance Verification Form and
return all required documents along with this application form to your SCU host department.
Section 1
Personal Information:
Date: ______________ SEVIS ID (Transfer Students Only): N______________________
SCU ID: _____________________________
Name (as it appears in passport) ___________________________________________________________________
(Family) (First) (Middle)
Email: ________________________________________Phone Number: __________________________________
Foreign
Address:______________________________________________________________________________________
_____________________________________________________________________________________________
Date of Birth: _________________ Gender: Female Male
(MM/DD/YYYY)
City of Birth: _______________________Country of Birth: ______________________________
Country of Citizenship: _______________________________
(For dual citizens, this must correspond to the country whose passport you use to enter the US)
Country of Legal Permanent Residence: _______________________
Section 2
Program Information:
a) Degree Level: Non-Degree Bachelor’s Master’s Ph. D.
b) Major: ___________________________________________
c) Period of stay in the US to be covered by the form DS-2019:
Fall Winter Spring Summer (Academic Year): __________________
d) Brief description of primary educational activity and duties in which you will be engaged:
__________________________________________________________________________________________

Section 3
The Purpose of this request: (check one)
Initial DS-2019 – the applicant is overseas and will be applying for a US visa abroad
Transfer – the applicant is currently in J-1 status at another US institution and will transfer to SCU.
Adding dependent (s): NOTE: children born in the U.S. do not need a J-2 visa.
Change of status to J-1 - You must see a Foreign Student Advisor to request this option.
Section 4
Financial Information:
During the period covered by this form, the total estimated financial support (in U.S. $) is to be provided by:
Santa Clara University $US______________________________
US Government Agency (ies) $US______________________________
International Organization(s)
$US______________________________
Exchange Visitor’s Government
$US ______________________________
Bi-National Commission of the Visitor’s Country $US ______________________________
Other Funding Source (please describe)
$US ______________________________
Personal Funds $US ______________________________
Section 5
Dependents * (ONLY your spouse and children can be your dependents)
Dependents are your spouse or child (ren) who are in the U.S. on a J-2 visa OR who will need to apply for
a J-2 visa to enter the U.S. If you have more then two dependents, please list on a separate sheet of paper.
For each dependent, please attach a photocopy of their passports.
Dependent 1 (as name appears in passport):
_____________________________________________________________________________________________
Last/Family or Surname First Name Middle name
___________ _____________________ ____________________ _____________________
Date of Birth City of Birth Country of Birth Country of Citizenship
Gender: Female Male
Relationship to you: Spouse Child
Dependent 2 (as it appears in passport):
_____________________________________________________________________________________________
Last/Family or Surname First Name Middle name
___________ _________________ _______________ _____________________
Date of Birth City of Birth Country of Birth Country of Citizenship
Gender: Female Male
Relationship to you: Spouse Child
I hereby certify that all the above information is correct, and agree to maintain health insurance that meets the
U.S. Dept. of State requirements for myself and my dependents for the full length of our stay in the U.S. I
understand that failure to do so may result in the termination of my J-1 program.
STUDENT SIGNATURE: ________________________________________________DATE:
_______________

Updated: 07/27/12