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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): ________ Last/Family Name ________ First/Given Name ________ Middle Name (if any)
Date of Birth ________ mm/dd/yyyy Gender: ☐ Male ☐ Female
Place of Birth ________ City ________ Province/State ________ Country ________
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
☐ Other (please describe)
Place of Employment/Study in Home Country (Company or Institution) ________
Contact Information
Address in Home Country: ________
Phone Number: ________ Email Address: ________
Position Information (Please provide information about your intended position with Kentucky State University) KSU Academic Department: ________ Supervisor's Name: ________
If Currently in the United States
Current Immigration Status: ________ Expiration Date of Current Status: ________ mm/dd/yyyy Document which shows your status (Please provide copy): ☐ 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