Skidmore College

Student and Exchange Visitor Program
Exchange Visitor Information Collection Form

* Required.

* SPONSORING ACADEMIC DEPARTMENT/DIVISION:

PERSONAL INFORMATION:
1. *Family Name:
2. *First Name:
3. *Full Name as it appears (or should appear) on Passport and/or Visa:
4 . Middle Name:
5 . Suffix:
6 . *Date of Birth (MM/DD/YYYY):
7 . *Gender:
8 . *City of Birth:
9 . *Country of Birth:
10 . *Country of Citizenship:
11. *Country of PERMANENT Residence:
12. Social Security Number:
13. Driver's License Number:
14. Driver's License Issue State:
15. Individual Taxpayer ID Number:
16. *Position at Skidmore: (stated in your Contract Letter from Skidmore)
17. Exchange Visitor Category:
18. Occupational Category: For Official Determinaion
19. Subject/Field Description: For Official Determinaion
20 . *U.S. Address
a . *Address 1:
b. Address 2:
c. *City:
d. *State:
e. *Zip Code:
21. Foreign Address
a. *Address 1:
b. Address 2:
c. *City:
d. *Country:
e. Province/Territory:
f. Postal Code:
g. Phone Number:
h . Email Address:
22. Creation Reason - a. Begin New Program
23. *Program Begin Date (MM/DD/YYYY):
24. *Program End Date (MM/DD/YYYY):

FINANCIAL INFORMATION:
1. 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:
a. *the current Program Sponsor (Skidmore College): $ (in U.S. Dollars)
b. *Skidmore College received funding for international exchange from one or more U.S. Government Agencies in support of this Exchange Visitor.
2. Financial support from organizations other than the sponsor will be provided by one or more of the following:
a. the Exchange Visitor's Government: $ (in U.S. Dollars);
b. the Binational Commission of the Exchange Visitor's Country: $ (in U.S. Dollars);
c. all other organizations providing support: $ (in U.S. Dollars);
i. Enter name(s) of other organizations providing support above:
d. *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:

1. Medical benefits of at least 50,000 per accident or illness;
2. repatriation of remains in the amount of $7,500;
3. expenses associated with medical evacuation of the exchange visitor to his or her home country in the amount of $10,000; and
4. a deductible not to exceed $500 (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 Skidmore College's Student and Exchange Visitor Program.

1. *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 Skidmore College 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
Skidmore College
Student Academic Services
815 N. Broadway
Saratoga Springs, NY 12866

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

e-Mail: mali1@Skidmore.edu

 

30-Apr-2012