Student and Exchange Visitor Program

Exchange Visitor Information Collection Form

Department: *

Personal Information

Family Name: *

First Name: *

Middle Name:

Full Name: * As it appears (or should appear) on Passport and/or Visa

Suffix:

Date of Birth: *

Gender: *

City of Birth: *

Country of Birth: *

Country of Citizenship: *

Country of PERMANENT Residence: *

Position at 91快活林: *

(stated in your Contract Letter from 91快活林)

Exchange Visitor Category:

U.S. Address

Address 1: *

Address 2:

City: *

State: *

Zip Code: *

Foreign Address

Address 1: *

Address 2:

City: *

Country: *

Province / Territory:

Postal Code:

>Phone Number:

Email address:

Program Begin Date: *

Program End Date: *

Financial Information

During the period covered by this program, the total estimated financial support (in U.S. Dollars) is to be provided to the Exchange Visitor by:

* the current Program Sponsor (91快活林): $ (in U.S. Dollars)
* 91快活林 received funding for international exchange from one or more U.S. Government Agencies in support of this Exchange Visitor.

Financial support from organizations other than the sponsor will be provided by one or more of the following:

the Exchange Visitor's Government: $ (in U.S. Dollars);
the Binational Commission of the Exchange Visitor's Country: $ (in U.S. Dollars);
all other organizations providing support: $ (in U.S. Dollars);
Enter name(s) of other organizations providing support above:
* personal funds: $ (in U.S. Dollars);

Insurance Coverage

All J-1 visa holders and their dependents are required by Student and Exchange Visitor Program (SEVP) and Department of Homeland Security (DHS) regulations to have health insurance with specific minimum coverage requirements while in the United States. The minimum coverage requirements that your health insurance policy must have as specified by the SEVP include:

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 the exchange visitor to his or her home country in the amount of $50,000; and
a deductible not to exceed $500 per accident or illness(22CFR 514.14)

An accompanying spouse or dependent of an Exchange Visitor is required to be covered by insurance in the same amounts [as the principal].

An Exchange Visitor who willfully fails to maintain the insurance coverage set forth above while a participant in an Exchange Visitor Program or who makes a material misrepresentation to the sponsor concerning such coverage shall be deemed to be in violation of these regulations and shall be subject to termination as an Exchange Visitor participant.

* I certify that I have or will have insurance coverage which meets the above requiremens in effect for the period of time during which I am an Exchange Visitor participant in 91快活林's Student and Exchange Visitor Program.

Name, address and phone number of organization or company providing insurance (no limit to amount of text entered in box below): *

Dependents (J-2 status)

* I dependents accompany me.

* I have prior authorization from my Sponsoring Academic Department at 91快活林 to have accompany me during my Exchange Visitor Program. (Each dependent that wishes to accompany a J-1 Exchange Visitor in J-2 status must have a record and will be issued his or her own individual Form DS-2019.)

Please complete a separate "Add Dependant" form for each dependent.
Add all dependents BEFORE submitting this form.

If you have questions, please contact:

Mir "Subhan" Ali
International Student & Scholar Advisor
91快活林
Student Academic Services
815 N. Broadway
Saratoga Springs, NY 12866

Direct: (518) 580-8150
Fax: (518) 580-8149

e-Mail: mali1@91快活林.edu

91快活林