Request for Exchange Visitor Status (J-1)

Approximate beginning date of program * / MM / DD YYYY
Approximate ending date of program * / MM / DD YYYY
Surname (Family Name) *
Given Name (First Name) *
Middle Name *

If you do not have a middle name, type NONE.
Requested Category at UCA *
Email *
Telephone Number *
Date of Birth * / MM / DD YYYY
Gender * Male Female
Mailing Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Address where you would like your documents mailed.
Home Country Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Personal Address
City of Birth *
Country of Birth *
Country of Citizenship *
Country of Permanent Residence *
Position in Home Country *
If "other" please list
Home Country University *
Program of Study *
Exchange Visitors are required to have major medical insurance coverage that meets the following requirements: $100,000 per accident or illness for medical expenses; $50,000 for medical evacuation; and $25,000 for repatriation of remains. **Exchange visitors who do not maintain health insurance will be in violation of J-1 requirements and their program will be terminated immediately. Students - insurance charges are automatically added to your student account if using the UCA international insurance. Research Scholar or Professor - are required to use the UCA international insurance. You may make one payment upon arrival or two payments if your program is longer than 6 month.

Students, are you going to use insurance from your home country? * Yes No
(If no, please provide a copy of your policy IN ENGLISH so that we may verify minimum requirements.)
Please provide specific information (in USD) for how you will finance your study at UCA. Students who will pay tuition and fees at UCA should demonstrate a minimum amount of $8,500.00. Students who will pay tuition and fees at their home institution should demonstrate a minimum amount of $4,000.00. If you are bringing a dependent, you should demonstrate an additional $3,500.00. For each additional dependent, you must demonstrate an additional $1,500.00 per person. Research Scholar, Short Term Scholar or Professor - must show financial support of at least $1300 per month. *
Has any of your financial support been received from the U.S. government? * Yes No
Have you been in the United States on a J-1 or J-2 visa in the past? * yes - less than 6 months yes - more than 6 months no
Please provide the name, address, telephone number of the person that should be contacted in case of emergency. *
Does your emergency contact speak English? * Yes No.
If your emergency contact does not speak English, what language do they speak? *
Do you give your permission for UCA to contact the person listed above in case of emergency? * yes no
Please type your full name in the box below to confirm that all information submitted in this application is true and correct to the best of your knowledge. *