Massachusetts Institute of Technology Tel: 617-253-2851

50 Ames Street Fax: 617-253-6624

Building E18-209 Email: [email protected]
Cambridge, MA 02142 web.mit.edu/scholars

Form B: Scholar Information

Request for J-1 Exchange Visitor visa sponsorship for scholars who will be on academic appointment at MIT. The
prospective scholar should complete this form and return it to the MIT department, laboratory, or center headquarters.
Please type or write clearly. This information will be used to issue the government-controlled Form DS-2019. Attach to
Form B:
• Copies of the biographical information pages from the passport (listing name and birth date), for yourself and any
accompanying family members.
• If you were in the U.S. in any status other than tourist, copies of previous visa documents, such as Form DS-2019
(for J-1); I-20 (for F-1); work authorization card (EAD); or H-1B, TN, or O-1 approval notice.

Please Note: International scholars on J-1 visas sponsored by MIT are permitted to engage in teaching and research at
MIT only, unless written permission for other locations is granted in advance by the MIT International Scholars Office.

Personal Information
Name (as it appears in passport)
Family Name Given Name(s)

Current address: E-mail:

Gender: � Male � Female Date of Birth (Month/Day/Year)

Place of Birth (City, Country) Country of Citizenship

Country of Legal Permanent Residence

Last Position Title in Home Country* [graduate student, researcher, professor, etc.]

Name of Last Employer/Institution in Home Country*

*Country of citizenship or country of legal permanent residence, if more recent.

Highest academic degree earned at start of MIT appointment: � Doctorate. Date received (Month /Year):
� M.D. � Masters � Other:
If you are currently a PhD student, will you obtain the PhD before the MIT appointment starts? � No � Yes
Expected completion date:
Will you be enrolled in a degree program or pursuing a degree elsewhere while on appointment at MIT? � No � Yes

Family Information
What is your marital status? � Single � Married / Spouse’s email, if J-2 will be requested:
Do you have family members who will need visa documents from MIT to accompany you? � No � Yes
Family members are currently in the U.S.: � No � Yes, their current visa status is

Do you have any family member(s) who is a US citizen or permanent resident? � No � Yes, relationship:

Please complete the following for all family members who will need J-2 visas to accompany you. Only your spouse and
children under age 21 may be included as J-2 dependents. Children cannot remain in J-2 status after their 21st birthday.
Use a separate page if necessary.
Name Gender Relationship Date of Birth Place of Birth Nationality Permanent Residence
(Family, Given names) (Female, Male) (Spouse, Child) (Month/Day/Year) (City, Country) (Country) (Country)

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U.S. Visa History
Are you currently in the United States? � No � Yes, my current visa status is .
If yes, do you have plans to depart the U.S. and re-enter before beginning your MIT appointment?
� No � Yes. Destination and dates of travel:
Have you ever been in the United States as a J-1 or J-2 Exchange Visitor? � No � Yes
If yes, are you subject to 212(e), the 2-year home residency requirement? � No � Yes � Not Sure
If yes, have you applied for and received a waiver, or a recommendation for a waiver? � No � Yes (attach copy)
Have you ever filed, or has someone filed for you, an application for U.S. permanent resident status? � No � Yes

List your visits to the United States during the past 6 years in all visa categories except tourist. Begin with most recent
date. Use a separate page if necessary.
Visa Status Start and End Dates of Visa Status Purpose of Stay and Location (School or Institution)

Information about the Prospective Appointment

MIT Faculty Host MIT Department/Lab/Center
Location of work: � MIT � Other location:
Proposed Dates* of the MIT Appointment: From to
*Please read important information on p. 4
Is it possible this appointment will continue beyond this end date? � No � Yes
Do you plan to go to another institution as a J-1 scholar before or after the MIT appointment ends? � No � Yes
If Yes, Name of the other institution:
Dates: From (month/day/year) to (month/day/year)

Financial Support from All Sources (for duration of MIT appointment as listed above)
Funding must cover the entire period of the MIT appointment and meet specified funding levels (see financial minimums,
below). Please provide supporting documentation for funding coming from all sources other than MIT.
Institution Full Name (do not abbreviate) Amount in U.S. $
MIT _________________________________
EV’s home Government (specify): _________________________________
Other Organization (specify): _________________________________
Personal Funds*
Total Amount of support for the appointment period……………………………….Total U.S.$
* May not exceed 10% of total support for principle visitor (not applicable to postdocs).
Financial Minimums
• The VP for Research sets a minimum salary for all postdoctoral scholars based on years of experience.
Faculty supervisors must ensure that postdoctoral scholars are compensated at the appropriate level through salary,
fellowship, and/or supplement. When fellowships do not meet the required minimum, additional compensation must
be provided. For more information, contact the personnel administrator or administrative officer in your MIT
department, lab, or center.
• All other J-1 Exchange Visitors must show proof of at least $35,000 in funding per year, with an additional $5,000
required, per year, for each accompanying dependent.

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 Health Insurance Information
If you will receive a salary from MIT and will be appointed for at least 3 months, for at least 50% effort, then you may be
eligible for MIT benefits, including MIT-subsidized health insurance. Eligibility for some plans, including the dental plan,
requires a longer appointment period. More information is available at http://hrweb.mit.edu/benefits/eligibility/. Please
speak to the personnel administrator in your MIT department, laboratory, or center to confirm whether you are eligible for
MIT benefits.

If you are NOT eligible for MIT benefits (not paid by MIT), but will have an MIT appointment for at least 3 months, then you
may be eligible to enroll in the MIT Affiliate Health Plan. You may also purchase health insurance from another U.S.
health insurance company or bring health insurance from your home country, as long as it meets the requirements listed
below.

After confirming if you are eligible for an MIT employee health plan or the MIT Affiliate Health Plan, please check one of
the following:
� I plan to enroll in an MIT employee health plan (the Traditional Health Plan or the Choice Plan).
� I plan to purchase the MIT Affiliate Health Plan or another health plan from an insurance company in the U.S.
Note: The MIT Affiliate Health Plan always starts on the first and 15th of the month; it cannot be pro-rated for part of a month.
� I plan to bring insurance from my home country.
Note: You will have to submit a copy of your health insurance coverage summary to the MIT Health Plan Office.

More information on the MIT health insurance plans, including the cost, is available at:
MIT employee health plans http://hrweb.mit.edu/benefits/health/plan-rates:
MIT Affiliate Health Plan: https://medical.mit.edu/mit-health-plans/affiliate-health-plans

Statement of Compliance with Exchange Visitor Health Insurance Requirements

J-1 exchange visitors and their J-2 dependents must be covered by illness and accident insurance for the duration of their
stay in the United States. Failure to purchase such insurance may lead to loss of legal immigration status and termination
from the Exchange Visitor Program. These U.S. Department of State (DOS) regulations are published in the Code of
Federal Regulations [22 CFR 62.14]. Minimum health insurance coverage must provide:

1) Medical benefits of at least $100,000 per accident or illness;

2) In case of death, repatriation of remains in the amount of $25,000;
3) In case of serious illness or injury, payment of expenses associated with the medical evacuation of the Exchange
Visitor to his or her home country in the amount of $50,000
4) A deductible not to exceed $500 per accident or illness; and
5) Co-insurance (co-pay) not to exceed 25%.

Two of the MIT employee health plans (the MIT Traditional Health Plan and the MIT Choice Plan) and the MIT Affiliate
Health Plan meet the DOS J-1 requirements. The MIT High Deductible Health Plan for employees does NOT meet the
DOS J-1 requirements and you should not select this plan if you are a benefits-eligible J-1 visa holder.

The regulations continue: “An Exchange Visitor who willfully fails to maintain the insurance coverage set forth above … or
who makes a material misrepresentation to the sponsor [Massachusetts Institute of Technology] concerning such
coverage shall be deemed to be in violation of these regulations and shall be subject to termination as a participant.” [22
CFR 62.14(i)]

All J-1 exchange visitors must sign the following statement:

I understand the insurance regulations as stipulated by the DOS, and I certify that I have the required insurance or will
enroll in an insurance plan or combination of plans to meet the specifications within 30 days of my J-1 program start
date. I further certify that I will also enroll all dependents who currently accompany me or who follow to join me in J-2 visa
status within 30 days. I also understand that if I willfully fail to purchase appropriate insurance coverage, the Institute is
obligated to terminate me from its Exchange Visitor Program and will notify the DOS that I have been so terminated. Such
action will result in my loss of legal immigration status.

Name (printed) Signature Date

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Emergency Contact Information . ⃞ Person is inside the U.S. ⃞ Person is outside the U.S.
..

Name Relationship

Phone # 1 + Phone # 2 +
Country code Country code

E-mail Address

Choice of J-1 Category

The International Scholars Office will select the appropriate J-1 category based on the information provided by the MIT
department, laboratory, or center and the prospective international scholar.

J-1 Research Scholar Category*

MIT brings most international scholars in this category. It is for scholars whose appointments are expected to be longer
than six months. Research scholars are primarily expected to be conducting research, but may also engage in teaching.
MIT policy allows Research Scholars to remain at MIT for up to three years, with extensions up to five years (the
maximum under the regulations) under certain circumstances.

J-1 Professor Category*

International scholars whose duties will primarily be teaching and whose stays are expected to be longer than six months
are brought to MIT in this category. Research duties are also permitted. MIT policy allows scholars in the Professor
category to remain at MIT for up to three years, with extensions up to five years (the maximum under the regulations)
under rare circumstances.

* Restriction on repeat visits in the J-1 Research Scholar or Professor categories: The J-1 regulations state that
international scholars who complete a J-1 stay in the Research Scholar or Professor category and their J-2 dependents
may not return to the U.S. in the future for another J-1 program in the Research Scholar or Professor category until 24
months have passed.

J-1 Short-term Scholar Category

This category is for scholars coming to the United States for no longer than six months. Extensions are not possible. This
category is appropriate for scholars whose visits will be short and will not exceed six months, or for scholars who may
come and go periodically to MIT. Repeat or back-to-back, six-month short-term scholar documents/programs are not
permitted.

J-1 Specialist Category

MIT bring scholars to the U.S. in this category under special circumstances and for certain types of appointments only.
The maximum limit for a J-1 program in the Specialist category is one year.

Graduate Students
Someone who is currently a graduate student elsewhere (and who will not yet have completed the degree prior to the start
of the MIT appointment) is not eligible for academic appointment or J-1 sponsorship through the International Scholars
Office, but may wish to come to MIT as a “visiting student.” Please speak with the inviting MIT department, laboratory, or
center about the required visiting student qualifications.

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