6

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 ________ mm/dd/yyyy 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

☐ 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
Address in Home Country [1]

Contact Information

Address in Home Country [2]
Address in Home Country [3]

Address in Home Country: ________

Phone Number
Email Address
KSU Academic Department
Supervisor’s Name

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

Expiration Date of Current Status
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