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Sections 1, 2, & 3 to be completed by International Applicant and submitted to Host Department with required documentation. Be sure to type or print clearly.

Section 1: J-1 Visitor's Demographic Information

Name and Residence Information

Full Name (as in passport
First/Given Name
Middle Name (if any

Date of Birth ________ Gender: ☐ Male ☐ Female

Date of Birth
Gender
Gender
[1]
undefined
Place of Birth
Citizen and Residence
[2]

Citizen and Residence: ________ Country of Citizenship ________ Country of Permanent Residence

Current or Last Job Position/Employment in Home Country (not in the U.S.)

Student
If Student
Graduate Student (Ph.D. or Master’s) or
Undergraduate Student (Bachelor’s

☐ Professor or Researcher

Professor or Researcher

☐ Other (please describe)

Other (please describe
Place of Employment/Study in Home Country (Company or Institution

Contact Information

Address in Home Country [1]
Address in Home Country [2]

Address in Home Country: ________

Address in Home Country [3]

Phone Number: ________ Email Address: ________

Phone Number
Email Address

Position Information (Please provide information about your intended position with Kentucky State University) KSU Academic Department: ________ Supervisor's Name: ________

KSU Academic Department
Supervisor’s Name

If Currently in the United States

Current Immigration Status: ________ Expiration Date of Current Status: ________

Expiration Date of Current Status

Document which shows your status (Please provide copy): ☐ I-797 Approval Notice ☐ DS-2019 ☐ I-20 ☐ I-94

I-797 Approval Notice
DS-2019
I-20
I-94

If currently in J-1 Status, which category are you? (Please provide a copy of current DS-2019): ☐ Professor ☐ Research Scholar ☐ Short-Term Scholar ☐ Student ☐ Other

Professor
Research Scholar
Short-Term Scholar
Student
Other