Exchange Visitor Information Sheet - For Professors, Researchers, Professionals, and Selected Students

In order for the Office of International Students and Scholars at Lewis & Clark College to issue the documents necessary for you to obtain a US Exchange Visitor (J-1) visa, you are asked to complete the following information. Please type or print clearly. Complete every question.

1. Name as in passport: (Family, F M) __________________________________________

2. Date of birth (Month/Day/Year)_________________________

3. Gender ____________

4. Citizenship_____________________

5. Country of residence ____________________

6. City and province of birth____________________

7. Country of birth________________

8. Sponsoring department/division at L&C: ______________________________________

9. Title/Position at L&C _____________________________________________________

10. Field of study at L&C ____________________________________________________

11. Career position in your home country _______________________________________

12. Contract/Attendance dates at L&C:

From: (mm/dd/yyyy) ________To: (mm/dd/yyyy) ____________

13. Desired date of arrival in US (mm/dd/yyyy)_________________________

14. Desired date of departure from the US (mm/dd/yyyy) ___________________________

15. Are you currently in the US?____________

15(a). If so, on what type of visa?__________

16. List all visits to the US during the past three years: Include dates of visit, the type of visa you used, and the purpose of the visit.

17. US Social Security number (if you have one) __________________________________

18. If you will be a student at L&C—Amount and Source of support (Please indicate below):

•Tuition Support and Source: $ ___________________ Source ____________________
•Housing allowance: $ __________________ Source_____________________________
•Food allowance: $ _______________ Source_________________________________
•US government support $_________________________Agency:__________________
•Grants/Stipends being received: $ ____________ Source ______________________
•Personal Funds: $ ______________________
•Any other funding being received : _____________ Source_________________________

19. If you will be a professor, researcher or professional at L&C (Please indicate below):

•L&C Salary for time period listed in #12: $ ____________
•Housing allowance: $ ____________________________
•Food allowance: $ _______________________________
•US government support $_________________________Agency:_________________
•Grants/Stipends being received: $ __________________
•Personal Funds: $ ______________________
•Any other funding being received : _____________________

20. If you will be paid by L&C, our Business Office needs the following information to issue a check:

A. Your Social Security Number (if you have one):_____________________________
B. Your permanent tax address: Enter your complete address for the country where you live permanently for tax purposes. Do not use a Post Office box or an “in care of” address:
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________

C. Your Father’s name: (First, Middle, Surname)________________________________
D. Your Mother’s Maiden Name: (First. Middle, Maiden Name)______________________
E. Your country’s tax identification number:________________________________
F. Your passport number: _______________________
G. Country issuing your passport:____________________
H. Type of US Visa (if you currently have one):____________________________
I. The number of your US visa (if you currently have one):_______________________

21. Marital status __________

21(a). If married, will your spouse and children accompany you?_________ (Note: For information on the costs of accompanying dependents, refer to the “Dependent Expenses” website at http://www.lclark.edu/offices/international/admitted/money/ugdependents/

22. List the names, relationship, birthdates, and places of birth of dependents who will accompany you.

23. Amount and source of funding for your dependents (attach proof).

24. Federal law mandates special health insurance for all Exchange Visitors and their dependents. (Insurance must meet US government guidelines including certain minimums, repatriation of remains, medical evacuation costs in the event of accident, etc.). Insurance for an Exchange Visitor costs approximately $90 to per month; costs for family members can cost from $400 or more per month). (Note: For information on insurance, refer to the “Health Insurance Options” website at: http://www.lclark.edu/offices/international/admitted/health_insurance/insurance/)

If Lewis & Clark is providing insurance coverage for you, please check the source of funding below:

_____ Faculty Contract/Personnel Office:
_____To be arranged in the Office of International Students and Scholars and charged to:
(Department name) ________________

25. Housing Arrangments: Please list the address and telephone number at which you and your dependents will live while in Portland.

26. Permanent address (in home country):

27. List the address where you want to receive the US INS documents. Print carefully.

28. Your e-mail address ____________________________________________________

29. Your telephone number (with country & city code) _____________________________

30. Your fax number (with country & city code) __________________________________

Please return this form by email attachment or by fax to:

International Students and Scholars
MSC 192 - Lewis & Clark College
0615 SW Palatine Hill Road
Portland, OR 97219-7899
TEL: 503-768-7305
Email: bdwhite@lclark.edu
FAX: 503-768-7301
Backup Fax: 503-768-7320