Request Form for an Exchange Student DS-2019 - College of ...

Request Form for an Exchange Student DS-2019INSTRUCTIONS:Students: Please complete items 1-10, and the Financial Certification Section.Departments: Please complete items 11-17 and include a copy of the admission letter.1) NAME (Name must appear exactly as it is written in the passport)____________________________________________________________________________________________________(Family/Last Name) (First/Given Name) (Middle Name or “None”)2) Date of Birth: ______/_______/_________ 3) Gender: _____ Male _____ Female(Month) (Day) (Year)4) City of Birth: ____________________________________ Country of Birth: ____________________________________5) Country of Citizenship: ______________________________________________________________________________6) Country of Legal Permanent Residence: ________________________________________________________________7) Status in Home Country: ___ Undergraduate Student ___ Graduate Student8) Name of university, school, or college referenced in # 7:___________________________________________________9) Student’s e-mail address:____________________________________________________________________________10) Address to which DS-2019 form should be sent (complete with postal code):_________________________________________________________________________________________________________________________________________________________________________________________________City State/Province (if applicable) Postal Code CountryTelephone #:__________________________________________________________________________11) BANNER ID:_________________________________12) Duration of Stay at W&M : From ______/_______/_________ to ______/_______/_________(Month) (Day) (Year) (Month) (Day) (Year)13) Description of program at W&M (what courses or program of study)_____________________________________________________________________________________14) Is this part of a formal exchange agreement between W&M and the student’s current institution? ________15) Mailing instructions: [ ] Reves sends: ____ airmail: Banner Index:______________________________ UPS: UPS Acct #_______________________________[ ] Department will pick up _____16) Department contact person for this request:___________________________________________17) Include a copy of the student’s letter of admission. Send all forms and information to Reves Ctr.

The College of William and MaryCertification of Financial Support forInternational Exchange StudentsAcademic Year 2012-2013This form and the estimates herein are provided solely for DS-2019 issuance. All international exchange students who will apply forJ-1 visa/status must show adequate financial support for their program of study in the United States. The necessary immigrationdocuments (DS-2019), cannot be issued until William and Mary has received a completed Certification of Financial Support and anysupporting documents.All documentation and signatures must be legible and not more than 6 months old at the time of admission. Scanned and faxedcopies are acceptable; however, students also need to present their original documents of financial support to the U.S. Consulate orEmbassy when they apply for their visa and again at the U.S. Port of EntryInternational Exchange Student Financial Estimates for 2012-2013 Academic Year (9 month period)It is assumed tuition is included in your exchange agreement. Below are estimated living expenses.ProgramLiving Expenses1 semesterLivingExpenses2 semestersGraduate Arts & Sciences,Graduate Education$7,121 $14,243Law (LLM, JD) $7,121 $14,243MBA, Master of Accounting $7871 $15,743Undergraduate Program$6865 $13,730INSTRUCTIONS: Look at the chart above to determine the amount of funds you must show to obtain your DS-2019. You must showfunding that meets the estimate provided for your program. Then read below to determine which sections you must complete onthe following page. This form must be submitted to the department/program that admitted you.Section 1: All students must complete Section 1.Sections 2 & 3:Complete these sections if you, your family, or a sponsor (e.g. friend, company) will fund all orpart of your education. Complete a separate Section 2 & 3 for each sponsor including yourself.Note: Students receiving a scholarship, fellowship, or funding from your company or organization: Complete Section 1, and attacha copy of the letter from the College, Agency, or Organization providing the funds. The amount to be awarded must be included. Ifyour award does not cover the total estimated costs, you will need to include funding from personal funds or a sponsor, and completeSections 2 and 3.Do you have questions on how to complete this form? Please e-mail globe@wm.edu.

SECTION 1: FINANCIAL STATEMENTStudent’s Name:_______________________________________________________________________________________(Last/Family Name) (First/Given Name) (Middle)Sources of Financial Support:Funds from Family/Sponsor (Complete Sections 2, 3)……………………………………………… U.S. $ ____________Personal Funds (Complete Sections 2, 3).…..…………………………………………….…………….. U.S. $ ____________Funds from The College of William and Mary…(attach letter)……………………………………… U.S. $ ____________Funds from a Government Agency or other Organization…(attach letter)…………………………… U.S. $ ____________TOTAL SUPPORT for first year at William and Mary….…….………...……................................... U.S. $ ____________Applicant’s signature: By signing your name to this form, you certify that the information you have provided is a correctstatement of the financial support for your studies at William and Mary.______________________________________________________________________________________________________SignatureDate: Month/Day/YearSECTION 2: AFFIDAVIT OF SUPPORTInstructions to student: Please remember to complete a separate Section 2 and 3 for each sponsor including yourself.I, ___________________________________________(name), guarantee that the sum amount of (US dollars)$____________ will be available for the above-named student for the first academic year at The College of William and Mary.A comparable amount of money will be available for ___ months. I understand that this statement is being used for thepurpose of issuing a U.S. government document._______________________________ ________________________________________________ ____________________Sponsor Signature Sponsor printed name Date (month/day/year)Sponsor Contact Information: E-mail: ____________________________ Tel:________________________________Mailing address:_________________________________________________________________________________________________________________________________________________________________SECTION 3: CERTIFICATION OF BANK OFFICERInstructions to bank officer: Please complete this section to verify the amount of funds that are available in the accountlisted in section 2 of this form. In place of completing this section, an official letter from the bank, in English and in USdollars, is acceptable.Name of Account Owner: ______________________________ Name/type of Account: ___________________________I certify that the Account Holder listed above has on deposit, at this bank, as of today’s date, funds of at least$______________ in U.S. Dollars to support the annual educational expenses at The College of William and Mary inWilliamsburg, Virginia, USA. This certification is offered with no responsibility on the part of this financial institution.______________________________ __________________________________________________ _________________Signature of Bank Officer Name and Title Date(month/day/year)Name of Bank: _________________________________________________Bank Address: _________________________________________________Number and Street______________________________________________________________City State/Province Country Postal CodePLACE BANK SEALHEREBank Telephone: ______________________________________________