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 WORCESTER STATE COLLEGE

VISITING SCHOLAR APPOINTMENT FORM

The information in this form is required for the International Programs to complete the DS2019 that scholars need to apply for a J visa from a U.S. Consulate of Embassy. Please make sure the information in the form is correct and that all the information requested is provided. Without the requisite information, the DS2019 from can not be completed.

Name of the Scholar (family/first/Middle):_____________________________________

Date of Birth: ____________________         Citizenship: _________________________

City/Country of Birth:__________________________________________________

Country of Legal Permanent Residence: __________________________________

Category of visitor:

_____ Professor—the exchange visitor will participate primarily in teaching, lecturing, observing or consulting WSC

_____ Research Scholar— will conduct research, observe or consult in connection with research project

_____ Short-term Scholar – The professor or research visits WSC for a maximum duration of four months

_____ Trainee – An individual participating in a structured training program in specialty and non-specialty occupations

Institution Affiliation in Home Country: _____________________  

Position in Home Country:___________________

Beginning and End dates if Appointment (d/m/yy):

 _____________________________________________________

 Does the scholar currently has a valid U.S. visa: ____yes  ______no                       

If yes, which visa: (J,F,B, etc.)__________

Will the visiting scholar be accompanied by dependents? If so, attach a list of names of dependents, relationship to scholar, birth dates, place of birth and nationality for dependents.

1. Summarize the scholar’s academic program at WSC (specify teaching, research and other responsibilities):

2. What specific support will the department provide the scholar? (access to office space, computer, clerical or other services):

3. Provide detailed information on financial support:

The scholar’s government                                                       $_______________

The bi-national Commission of the visitor’s country             $_______________

The exchange scholar’s home institution                                 $_______________

WSC                                                                                        $_______________

Other organization (Name:____________________)             $_______________

Personal funds                                                                         $_______________

* International Programs will need written confirmation from the sponsoring agency of the funding support. The scholar will need a bank statement attesting to funds from personal resources, if these funds are integral to the exchange program

SIGNATURE ROUTING

Department Chair                                                                                                        Date

Director, International Programs                                                                                 Date

Associate Vice-President for Academic Affairs                                                         Date

           | International Programs | study.abroad@worcester.edu| 508.929.8104