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HYPERLINK "http://www.ramapo.edu/"  INCLUDEPICTURE "http://www.ramapo.edu/css2/images/ramapoLogo.gif" \* MERGEFORMATINET ROUKEMA CENTER FOR INTERNATIONAL EDUCATION 505 鶹 Valley Road, ASB 123, Mahwah, NJ 07430-1680 Phone (201) 684-7567 Fax (201) 684-7989 www.ramapo.edu/international APPLICATION FOR INTERNATIONAL J -1 STUDENT/SCHOLAR Please check one New Application: ____ Transfer: ____ Check-In: ____ Update Information: ____ (Personal ____ Immigration ____ Financial ____ Department ____Dependent ____ )  Personal Information (Please type or print clearly) Name: (as in passport ID page):_________________________________________________________________________ Family Name Given Name Middle Name All other Names used (including maiden name, if applicable): ________________________________________________ Date of Birth: ______/______/______ Gender: Male____Female ____ Marital Status: Married ____ Single ____ mo day yr Country of Birth: _______________ City/Province of Birth: ________________ Country of Citizenship: _____________ U.S. Home Address (if in the U.S.): _____________________________________________________________________ Street Apartment ______________________________________________________________________ City State Zip Telephone: __________________ Fax: ______________________ Email: __________________________________ Foreign Address (HOME): ____________________________________________________________________________ Street ____________________________________________________________________________ City Country/Province Zip/Postal Code Telephone: ___________________ Fax: _______________________ Email: __________________________________ Job Title in Home Country: _________________________ Employers Name/Address: ____________________________ Immigration Information Passport Number: _______________ Passport Issue Date: _____/____/____ Passport Expiration Date: _____/____/____ mo day yr mo day yr Have you ever held a J-1 visa status? YES ___ NO ___ (if YES please provide dates and copies of all previously issued DS-2019) From: __________________ To: __________________ (Please complete the following ONLY if currently in the United States) Date of last arrival: _______________ Current visa status: ______________ Expires on: ______________ I-94 number (white card in your passport): _________________________ I-94 Expiration Date: ____/____/____ D/S: __ mo day yr Visa Number (red number on visa): ______________________ Visa Control Number: ______________________________ Visa Expiration Date: ____/____/____ Place of Visa Issuance: ________________ Date of Visa Issuance: ____/____/___ mo day yr mo day yr Highest Degree Completed Associates ____ Bachelors____ Masters_____ PhD.____ Financial Information (please provide original copies of all financial documents) Personal Funds: $________________ Government Funds (U.S.) $________________ Family Funds: $________________ Government Funds (Foreign) $________________ RAMAPO Funds: $________________ Other: $________________ TOTAL from all sources: $________________ Department Information (If currently in the United States) Name of the Department: __________________________________ Campus Address: ____________________________ Faculty Advisor/Supervisor: __________________________ Phone: _____________________ Email: _______________ Administrative Contact Name: ________________________ Phone: ______________ Email: ______________________ Dependent Information (ONLY if they will accompany you to the U.S.) 1. Name: (as in passport ID page):___________________________________________________________________________ Family Name Given Name Middle Name Date of Birth: ______/______/______ Gender: Male____Female _____ Relationship ___________________________ mo day yr Country of Birth: __________________City/Province of Birth: _____________________ Country of Citizenship: ______________ Passport Number: _______________ Passport Issue Date: _____/____/____ Passport Expiration Date: _____/____/____ mo day yr mo day yr If inside the U.S., please indicate date of last arrival: ____________ Current visa status: _____ Expires on: ____________ Visa Expiration Date: _____/____/____ Visa Issue Date: _____/____/____ Place of Visa issuance: _________________ mo day yr mo day yr I-94 number (white card in passport): __________________________ I-94 Expiration Date: _____/____/____ D/S: ____ mo day yr 2. Name: (as in passport ID page):__________________________________________________________________________ Family Name Given Name Middle Name Date of Birth: ______/______/______ Gender: Male____Female _____ Relationship ___________________________ mo day yr Country of Birth: __________________City/Province of Birth: ___________________ Country of Citizenship: ______________ Passport Number: _______________ Passport Issue Date: _____/____/____ Passport Expiration Date: _____/____/____ mo day yr mo day yr If inside the U.S., please indicate date of last arrival: ____________ Current visa status: _____ Expires on: ____________ Visa Expiration Date: _____/____/____ Visa Issue Date: _____/____/____ Place of Visa issuance: _________________ mo day yr mo day yr I-94 number (white card in passport): __________________________ I-94 Expiration Date: _____/____/____ D/S: ____ mo day yr Applicants Name _____________________________ Signature _________________________________ Date ______________ MEDICAL INSURANCE COMPLIANCE AGREEMENT Exchange visitors are required by law to have medical insurance in effect for themselves and any accompanying spouse and dependents on J visas. The insurance must be maintained for the duration of their program. Our office provides insurance brochures that meet the requirement or you may obtain your own coverage as long as it meets the requirements. If you wish assistance for an insurance program, please visit our office upon arrival so we can advise you. NOTE: Medical insurance policies generally do not cover pre-existing medical conditions. If you have a health condition that may require treatment in the U.S., you may be required to pay cash for such treatments. Minimum Coverage Required: Medical Benefits of at least $50,000 per person per accident or illness Repatriation of remains in the amount of $7,500 Expenses associate with medical evacuation in the amount of $10,000 Please answer the following questions: I do attest that I will comply with the terms and conditions of the J-1/J-2 mandatory health insurance requirements as outlined above. _____ YES _____ NO I understand that I jeopardize my Exchange Visitor status if I fail to comply. _____ YES _____ NO Your Name:____________________________ Signature: __________________________ Date: ___________  ESTIMATE OF EXPENSES Please provide evidence of sufficient funds to support your period of stay here in the US in order for International Services to issue you the DS-2019. RAMAPO salary/stipend information will be shown in the letter of appointment but if the funding is from other sources ORIGINAL documentation must be submitted. All documents must be translated in English and must be converted to US dollars. Cost Estimates Scholars only $1,800 per month $21,600 per year Dependents $416 per month per dependent $5,000 per year per dependent SPONSOR INFORMATION Please provide the following information and attach original copies of the supporting documents. Note: All financial resources must be in liquid assets-readily available to the visitor. Name of the Sponsor: ______________________________________________________________________________________ Last Name First Name Middle Name Address of the Sponsor: ____________________________________________________________________________________ ________________________________________________________________________________________________________ City State/Province Country Postal/Zip Code Day Time Phone Number: __________________________________ Evening Phone Number: ___________________________ Email: ____________________________________________________ Relationship to the Applicant: _________________________________________________ I herby certify that I will provide support for _______________________________________________ and the following number of accompanying dependents _____ to participate in an exchange program at 鶹 College, in the School/Department of _________________________________________________________. 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