Request Form & Instructions

J-1 Exchange Visitor (Scholar) Request Form –
Instructions
Preparing Documents to Request an Initial DS-2019
The Office of International Affairs (OIA) administers Nova Southeastern University’s Exchange Visitor Program.
Programs seeking to host a foreign scholar should complete the following form along with the requested supporting
documentation for submission to OIA.
In order to allow for administrative processing and in anticipation of visa application processes at American
embassies/consulates, please submit your request at least 60 days prior to the visitors anticipated appointment start
date.
Exchange Visitor Categories: This request form is only for the purpose of requesting the following classification or
category of visitors under the J-1 Exchange Visitor Program: 1) Professor, 2) Research Scholar, and 3) Short-Term
Scholars:
For detailed information on these exchange visitor categories, please visit our website: www.nova.edu/jscholars
Required Supporting Documentation: Along with the attached form, please ensure you also include the following
documents. Please submit all together in one email.
1) the completed and signed J-1 Scholar request form
2) a letter of invitation
3) proof of adequate funding
4) a copy of the scholar’s C.V. or résumé
5) certification of English language proficiency
6) copies of passports for both visitor and dependents (if any)
7) copies of previous DS-2019s (if any)
8) Program Attestation of Cultural Exchange
9) Exchange Visitor attestation of insurance
10) Exchange Visitor’s foreign address
11) Exchange Visitor’s foreign telephone number
For detailed information on all supporting documentation, please visit our website: www.nova.edu/jscholars
NEXT STEPS?
● After you have completed the attached form, email it to [email protected] including the required
supporting documentation.
● The OIA will review the request, determine the eligibility of the visitor, and prepare the initial DS-2019.
● The OIA will email the initial DS-2019 to the scholar at the email address included below, along with the
NSU sponsor. That email will contain the next steps the scholar needs to take before entering the United
States.
J-1 Exchange Visitor Request Form
(For Research Scholar, Professor, or Short-Term Scholar)
New program - scholar coming from abroad

1. The purpose of this request: New program - scholar transferring within the U.S.
Extension - scholar continuing on same program at NSU
2. Visiting Scholar’s Name:
(Last or family name) (First name) (Middle name)
3. Sex: Male Female 4 Date of Birth: (month/day/year)

.
5. E-mail Address: Foreign Telephone:
6. City and Country of birth.
7. Country of Citizenship: 8. Country of legal permanent residence:

Please note this may not necessarily be the same as
citizenship.
9. Present or former position in the country of permanent residence:
(For example: Is he/she a professor, researcher, doctor, graduate student, government employee/administrator, in
the private sector?)
10. Has the candidate been a J-1 scholar in the US? Yes No End date of most recent J-1 program
11. Proposed dates of stay: From: To:

(month/day/year) (month/day/year)
List the total period, up to a maximum of five years (Professor or Research Scholar) or six months (Short-Term
Scholar), for which the activities have been mutually agreed to and for which funding has been assured.
12. Title of proposed position:
13. Brief, concise, non-technical description of activities of exchange visitor at NSU (and work site address) :
For example: Research in the field of veterinary pathobiology, research in mathematics, etc.
14. Source and amount of financial support: Please note that this must be documented in the form of an offer
letter or, if the support is coming from the home institution or agency, documentary evidence must be attached to
this application before the OIA can prepare the scholar’s documents.
● Nova Southeastern University $ Source:
(includes departmental grant funding)
● Exchange visitor’s government $ Source:
● Other organizations (please list) $ Source:
● Personal funds $
15 Accompanying Family Members – If the exchange visitor’s spouse and/or children will accompany him/her
to NSU, the OIA must also issue to the exchange visitor, a certification listing the names (as they appear in their
passports) of the family members, their relationships to the exchange visitor and the dates and places of birth (city
and country). Each dependent will be issued his/her own J document, DS 2019, as a J-2 dependent.
Dependent #1
Relationship Date of Birth month/day/year Place of birth:
Spouse, City &
daughter, son Country
Country of Citizenship Country of Permanent Residency
Dependent #2

Spouse, City & Country
daughter, son
Dependent #3

Spouse, City & Country
daughter, son
Note: If more space is needed for additional dependents, please attach an extra sheet of paper. Be sure that all names
are spelled correctly and exactly as they are in the individual’s passport. A misspelling of a name can lead to a visa
denial.
16. Insurance Coverage (Medical, Evacuation, & Repatriation)

Please include medical insurance attestation attached when submitting this form.
● Medical benefits of at least $100,000 per person per accident or illness
● Expenses associated with medical evacuation in the amount of $50,000
● Repatriation of remains in the amount of $25,000
● A deductible not to exceed $500 per accident or illness
Note: Exchange visitors are required to have medical insurance that covers them for sickness or accident during
the period they are participating in NSU’s exchange visitor program. The visitor must provide proof of insurance as
indicated above to the OIA within two weeks of the start of the program listed on the Exchange Visitor’s DS-2019.
17. Information on Additional NSU Department Contacts responsible for hosting the Visiting Scholar:
Name (Student Supervisor): Title:
Dept Name and Address: Phone#: E-mail address:
Alternate dept. contact who may be of assistance in Phone#: E-mail address:

your absence:
Supervisor Signature: Date:
Name: (Department Head/Dean) Title:

Dept Name and Address (if different from above): Phone#: E-mail address:
Dean’s Signature: Date:
Name: (Human Resources Official) Title:

Dept Name and Address: Phone#: E-mail address:
HR Signature: Date:

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J-1 Exchange Visitor (Scholar) Request Form –

New program - scholar coming from abroad

2. Visiting Scholar’s Name:

(Last or family name) (First name) (Middle name)

3. Sex: Male Female 4 Date of Birth: (month/day/year)

6. City and Country of birth.

7. Country of Citizenship: 8. Country of legal permanent residence:

11. Proposed dates of stay: From: To:

12. Title of proposed position:

(Last or family name) (First name) (Middle name)

(Last or family name) (First name) (Middle name)

16. Insurance Coverage (Medical, Evacuation, & Repatriation)

Dept Name and Address: Phone#: E-mail address:

Alternate dept. contact who may be of assistance in Phone#: E-mail address:

Supervisor Signature: Date:

Name: (Department Head/Dean) Title:

Dean’s Signature: Date:

Name: (Human Resources Official) Title:

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