j-1 exchange scholar application (jesca) form...zzcompleted and signed j-1 exchange scholar...

J-1 EXCHANGE SCHOLAR APPLICATION (JESCA) FORM

Application Checklist:

zz Completed and signed J-1 Exchange Scholar Application form

zz $50 non-refundable application fee, due with application

zz Personal Plan and Goal Statement

zz Resume/CV

zz Copy of scholar’s passport photo and expiration date page(s)

zz Copy of dependent’s passport photo and expira-tion date page(s)

zz Financial verification documents

zz Program fee, due one month prior to arrival

zz Proof of English proficiency

zz BC Academic Hosting Division Sign-Off form

J-1 Exchange Scholar Application – Page 1

J-1 Exchange Visitor Program

Please select ONE of the following J-1 Exchange Visitor program categories you are invited to BC:

RESEARCH SCHOLAR (22 CFR 62.20) primarily conducts research, observes, or consults in connection with a research project at Bellevue Col-lege. The Research Scholar may also teach and lecture (unless disallowed by the BC Academic Hosting division/department) provided that these activities are incidental and do not extend the period of participation beyond the maximum duration. The duration of stay of participation is a 3-week minimum and not to exceed 5 years. Prior teaching or research while on a J visa sponsored by another organization in the U.S. could reduce the number of years of eligibility.

PROFESSOR (22 CFR 62.20) primarily involves teaching, lecturing, observing, or consulting at Bellevue College. A professor may also conduct research, unless disallowed by BC Academic Hosting department/division. The duration of stay of participation is a one quarter minimum and not to exceed 5 years. Prior teaching or research while on a J visa sponsored by another organization in the U.S. could reduce the number of years of eligibility.

SHORT-TERM SCHOLARS (22 CFR 62.21) is a professor, research scholar, or person with similar education or accomplishments coming to the United States on a short-term visit to lecture, observe, consult, train, or demonstrate special skills at Bellevue College. The duration of stay of participation is a 1-week minimum but shall not exceed 6 months. No extensions will be permitted.

SPECIALISTS (22 CFR 62.26) is for experts who will exhibit specialized knowledge or skills in the United States. Such exchanges are primar-ily non-academic and provide opportunities to increase the exchange of knowledge and ideas between American and foreign specialists. The duration of stay of participation is a 3-week minimum and a one-year maximum.

Please write a paragraph summarizing your Personal Plan and Goal Statement below. Please attach a separate sheet if more space is needed. Also please attach your resume/cv.

PART I: to be completed by the Exchange Scholar.


A. Biographical Information:

Enter names as they appear on the passport. Please refer to the Machine Readable Zone of your passport for your name appearance. Do not use any dashes (“-”), slashes (“/”, “\”), or special characters.

Full Name: ______________________________________________________________________________________________________________

Birth Date: ____________________________________________ Male Female

City of Birth: _______________________________________________ Country of Birth: ________________________________________________

Country of Citizenship: _______________________________________ Country of Permanent Residence : ___________________________________

Family Name/Surname Primary Given Name Middle Name

Month / Day / Year

B. Contact Information:

U.S. Address:

________________________________________________________

________________________________________________________

City: ____________________________________________________

State: ____________________ Zip Code: _______________________

Email: ___________________________________________________

Phone: ________________________ Fax: _______________________

Home Country Address (Non-U.S.):

________________________________________________________

________________________________________________________

City: ____________________________________________________

Province/State: ____________________ Zip Code: ________________

Country: _________________________________________________

Phone: ________________________ Fax: ______________________

C. Emergency Contact Information:

Name: ____________________________________________________________ Relationship: _________________________________________

Address: _________________________________________________ City: ___________________ State: ___________ Zip Code: ______________

Email: ____________________________________ Phone: ___________________ English Speaking: Yes No Which Language: ____________

D. Visa Information:

Are you currently in the U.S.: Yes No

If YES, what is your current nonimmigrant status? __________________________________ Duration of stay: _______________________________

For each prior visit to the U.S. (except as a B-1 or B-2 or Visa Waiver), list your nonimmigrant status and duration of stay each time. Please attach a separate sheet if there are more than four times:

1. Visa/Status: ________________________________________ Dates of Stay: ________________________________________




Are you transferring from another U.S. institution to BC? Yes No If YES, please complete the J-1 Scholar Transfer In Form

MM/DD/YY to MM/DD/YY





E. Employment Information:

Current Home Country Job Title: __________________________________ Employer’s Name: _____________________________________________

Department Name: _____________________________________Work Phone: _________________________ E-mail: _________________________

Supervisor’s Name: ____________________________________ Phone: _____________________________ E-mail: _________________________


F. Educational Background:

Type of School (College, University,

High School, etc.)

Name of School From – To (mm/dd/yy – mm/dd/yy)

Degree Level (High School diploma,

Associate, Bachelor’s, etc.)

Degree Completion Date (mm/dd/yy)

G. Financial Information:The breakdown costs below are suggestions of the minimum and required amounts. It is recommended that you should include the total amounts, SEVIS fee ($200), Visa fee ($160/each), and airfare to your initial budget. However, during your stay of the program, the only expenses you need are the health insur-ance fees, the social & cultural activity fees, and living expenses. Please note that the living expenses amounts are minimum amounts. Actual living expenses might be higher depending on where you stay and your lifestyle. The financial document(s) you are submitting to our office should show the amount that at least covers the ‘total monthly expenses’ for yourself and accompanying dependents for the entire period of stay.

EXPENSES (minimum suggestions & required)

PER MONTH

SCHOLAR (Primary)

SPOUSE (additional cost to the

Primary Scholar)

CHILD (additional cost for each child

to the Primary Scholar)

MONTHLY FEESHealth Insurance Fee $122 $122 $122

Social & Cultural Activity Fee $100 $100 $100

LIVING EXPENSES Monthly Fees

Room & Board (not to BC) $1,055 $1,055 $1,055

Transportation (not to BC) $144 $144 $144

Misc. (personal expenses) (not to BC) $199 $199 $199

One-Time Fee/Payment

Program Fee $4,000* $0 $0

Housing Placement Fee (not to BC) $300 $0 $0

TOTALS $5,920 $1,620 $1,620

*Program Fee – up to $4,000 depending on the duration and type of the program.

3. Calculate the “Total Monthly Funding Support”, (financial support), from all sources:• Home Country government or Organization Funding (if any, please specify): $ • BC Monthly Salary (if any): $ • Other BC Compensation (if any, please specify): $ • Personal Funds: $ • Other (please specify): $

TOTAL MONTHLY FUNDING SUPPORT $

4. Multiply the “Total Monthly Funding Support” by the number of months you will be at BC:

Total monthly funding support x (number of months) = $ TOTAL MONTHLY FUNDING SUPPORT FOR YOUR PERIOD OF STAY $

5. The “Total Monthly Funding Support” amount shown on #4 must be equal to or higher than the Total Monthly Expenses for you and yourfamily for the entire stay, shown on #2. FINANCES MUST BE VERIFIED. A document that verifies the above financial support (e.g., a BC Contract, a letter or contract from your home country university, or a bank statement showing availability of personal funds) must accompany this application.

1. Calculate the “Total Monthly Expenses” for yourself and accompanying dependents:J-1 (yourself), excluding all one-time fees = $1,620 $J-2 Spouse = $1,620 $J-2 Child = $1,620 x (number of children) = $

TOTAL MONTHLY EXPENSES $

2. Multiply the “Total Monthly Expenses” by the number of months you and your dependents will be at BC:

Total Monthly Expenses x (number of months) = $

TOTAL MONTHLY EXPENSES FOR YOU AND YOUR FAMILY FOR THE ENTIRE PERIOD OF STAY $


**Please provide the same required information above for additional children on a separate sheet, if any.

I. Dependent Information:

Please include only family members (dependents) who will accompany you to the U.S. and provide a copy of each dependent’s biographic and expiration information passport page:

CHILD #3 INFORMATION:

Passport Name: __________________________________________________________________________________________________________

Birth Date: ____________________________________________ Email Address: ______________________________________________________

Male Female City of Birth: ____________________________________ Country of Birth: ________________________________________

Country of Citizenship: ____________________________________ Country of Permanent Residence : ______________________________________

Family Name First Name Middle Name

Month / Day / Year


Passport Name: __________________________________________________________________________________________________________





Month / Day / Year


Passport Name: __________________________________________________________________________________________________________





Month / Day / Year

SPOUSE INFORMATION:

Passport Name: __________________________________________________________________________________________________________





Month / Day / Year

H. DS-2019 Requested Date & Referral Information:

Potential Arrival Date (mm/dd/yy): ________________________________________

Approximately how long will you be at Bellevue College?

3 months / 1 quarter 6 months / 2 quarters 9 months 1 year Other (specify): _________________________________________

Will you have any dependents with you: No Spouse _____ Child(ren) please provide their information below.

How did you hear about BC? Friend/Family BC Website Other (specify): ___________________________________________________


J. Scholar’s Attestment:

I hereby certify that the information I have provided above is accurate and complete to the best of my knowledge, and that FAILURE to disclose and submit complete and accurate information and all required documents may result in denial of admission or dismissal from Bellevue College (BC).

I do hereby also authorize BC to contact my relatives/friends as listed in the Emergency Contact Information section in cases of an emergency or medical situation.

I understand that as mandated by Federal law, all J-1 Exchange Visitors and their dependents must have medical insurance coverage in effect for the entire period of their exchange visitor program and coverage with the following minimum benefits [22 CFR 62.14]: * Medical benefits of at least $100,000 per accident or illness;* Repatriation of remains in the amount of $25,000;* Expenses associated with the medical evacuation of the exchange visitor to his or her home country in the amount of $50,000;* A deductible not to exceed $500 per accident or illness.

Check one of the following options that apply to you:

I will bring health insurance from my home country and will submit proof of my health insurance upon arrival.zI will purchase health insurance through Bellevue College.

Scholar’s Full Name (Print) Signature Date

K. Credit Card Authorization:

The required, non-refundable application fee of $50 and the required program fee can be made by cashier’s check or money order, credit card, or wire transfer.

I agree to pay:

Non-Refundable Application fee of $50 (due with application) Program fee of _________ (due now or one month prior to arrival date)

I will pay by cashier’s check or money order, payable to Bellevue College.

I will pay by wire transfer. Contact BC Global Initiatives office at [email protected] for wire transfer details.

I will pay by credit card – Please do not email your credit card information via the internet. Thank you!

Credit card holder’s name: ___________________________________________________________________________________

Credit card type: Mastercard Visa Debit Expiration date: __________ / __________

Card number: ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___ Code on the back: __________________

As the cardholder, or as a representative of the cardholder noted above, I hereby authorize the above charges.

Cardholder’s Full Name Signature Date

Please fax or email this completed application form and other required documents to:Bellevue College – Global Initiatives

3000 Landerholm Circle SE • Bellevue, WA 98007-6484 – USAFax: +1-425-641-0246 • Email: [email protected]


PART II: BC Academic Hosting Division Sign-off Form (to be completed by BC Academic Hosting Unit that is inviting the Exhange Scholar.) Please tear/cut off this page and send it to your Academic Hosting Division to complete. Once it’s completed, please submit it to the Global Initiatives office.

A. Appointment Information:

Proposed Dates of J-1 Sponsorship: DS-2019 forms are normally issued for up to one year. Extensions may be requested in increments up to one year. The DS-2019 may be issued to cover up to five years if the Sponsoring BC unit commits to pay full-time salary to the International Scholar for the entire duration of the stay.

Requested DS-2019 Start Date: _____________________________ Requested DS-2019 End Date: ______________________________

Exchange Scholar’s BC Activities: (Check as many as applicable)

Research Observation

Teaching Consultation with Colleagues

Demonstrating special skills Other, specify: _______________________________________________________________

List all activity locations. Please include the name of the organization/institution, street address, and zip code for off-campus locations. If there are more than 4 locations, please incude on a separate sheet.

1. Name ___________________________________________ From (date) _____________ To (date) ____________

Address ____________________________________________________________________________________


Address ____________________________________________________________________________________


Address ____________________________________________________________________________________


Address ____________________________________________________________________________________

Appointment Title at BC: ________________________________ Field of Specialization at BC: ________________________________

Exchange Scholar’s Supervisor at BC (print full name): _______________________________________________________________

Title of Supervisor: ______________________________________ Office Location _________________________________________

Phone: ______________________________________ Email: ________________________________________________________

English Proficiency Requirement:

A prospective Exchange Scholar must possess sufficient proficiency in English to successfully participate in the program and to function on a day-to-day basis. Federal law required sponsors (i.e., BC Academic Hosting Unit), to use one of the following ‘objective measurements’ and to retain evidence of how the BC Academic Hosting Unit determines the Exchange Scholar’s English language proficiency.

A recognized English language test; Signed documentation from an academic institution or English language school; OR A documented interview conducted by BC Academic Hosting department/division or by BC Testing Center, either in person or by videoconferencing, or by telephone if videoconferencing is not a viable option.

**Please provide a copy of the Exchange Scholar’s English language proficiency result to the Global Initiatives office before a DS-2019 form is issued.

MM/DD/YY MM/DD/YY


Bellevue College does not discriminate on the basis of race or ethnicity; creed; color; national origin; sex; marital status; sexual orientation; age; religion; genetic information; the presence of any sensory, mental, or physical disability; gender identity or veteran status in educational programs and activities which it operates... Please see policy 4150 at www.bellevuecollege.edu/policies/. PS 7-17

B. BC Academic Hosting Unit Information:

This appointment is Full-time Part-time Courtesy

BC Academic Hosting Unit Name: _________________________________________________________________________________

BC Hosting Unit Contact Details

Contact Person’s Name: _________________________________________________________________________________

Contact Person’s Email: [email protected] Phone: x _________________

BC Hosting Unit Budget Details:

Budget Number: _______________________________________________________________________________________

Budget Authority’s Name (print full name): ____________________________________________________________________

Budget Authority’s Email: [email protected] Phone: x ________________

BC Hosting Unit Approval Information:

Scholar’s Supervisor:

______________________________________________________________________________________________________

Dean or Program Chair (if different than supervisor):

______________________________________________________________________________________________________

VP of Office of Instruction (or designee):

______________________________________________________________________________________________________

Name (Print) Title DateSignature



Please inter-office mail or email this completed Division Sign-off form to Global Initiatives at:Mailstop: N211

Email: [email protected]

j-1 exchange scholar application (jesca) form...zzcompleted and signed j-1 exchange scholar...

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