5000 Forbes Ave, Cyert Hall, Suite 101, Pittsburgh, PA 15213
Phone: (412) 268-5231 ▪ Email: [email protected] ▪ Web: www.cmu.edu/oie
J-1 Student Intern Data Form
Instructions: This form is to be completed by the Student Intern and returned to the department coordinator. The
Student Intern should not send this form directly to OIE.
All information is required. Do not skip any item. Do not enter “NA” in any field.
A copy of the identification (picture) page of your passport must be included.
Name
Family/Last Given/First and Middle name
Date of Birth Gender: Male □ Female □ Marital Status: Single □ Married □
Month / Day / Year
City of Birth Country of Birth
Country of Citizenship Country of Legal Permanent Residence
What was your last position/title in your home country: ie: undergrad student or grad student, etc.
Current level of education: Doctorate □ Masters □ Bachelor □ Certificate □ Other
Name of current school/institution
Field of study at your home school/institution: Expected graduation date:
Your home country address:
Street Address
City State / Province Country
Postal code Phone number Email (personal)
Required Financial Support: Prior to issuing a DS-2019 Certificate of Eligibility, immigration regulations require
proof of sufficient financial support for the entire duration of the visit. For a student intern to the Pittsburgh campus, a
minimum of $30,564/year ($2,547/month) is required. For a student intern to the Silicon Valley campus, a minimum of
$36,072 per year ($3,006 per month) is required. If applicable, include an additional $14,964/year ($1,247/month) for
an accompanying spouse and $13,356/year ($1,113/month) for each accompanying child.
If receiving CMU department support, attach a copy of the offer/invitation letter. For home institution, employer or
home government support, submit letters on official letterhead clearly detailing the time period to be covered and the total
amount of support offered. If using personal funds, submit bank statements that meet the criteria below. If receiving
financial support from a family member, provide a letter signed by the family member and bank statements.
NOTE: Supporting financial documents must: 1) be in English, 2) be dated less than 6 months from date of
submission, and 3) clearly state the name of the account holder and the amount of funding available in U.S. dollar
equivalent. (Foreign currency will be converted upon review of the forms if necessary).
(Although we will be accepting financial documentation for student interns via email, the student is still expected
to maintain original financial documentation and OIE reserves the right to request that the student mail such
documentation if necessary.)
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1
Are you currently in the U.S.? No □ Yes □ If yes, what is your current visa status:
Have you previously been in the U.S. as a J-1 Exchange Visitor? No □ Yes □
If yes, complete the following:
Previous J-1 Program: Dates: from to
Purpose of visit (student, intern, researcher, etc)
Visa Sponsor (name of host university, Fulbright, etc)
Have you ever applied for a waiver of the two-year home residency requirement? No □ Yes □
If yes, have you received any official (USCIS, DOS) notification regarding this application? No □ Yes □
If you are in the US now or have been in the US in J-1 visa status previously, submit a copy of your immigration
document (I-20/DS-2019 and I-94).
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Complete the following section only if family members (spouse and/or minor children) will accompany you to
the U.S. Include a copy of the identification (picture) page of the passport for each member.
Dependent 1
Name /
Family / Last Name Given / First Name and Middle Name
Date of Birth Relationship to visitor (spouse, son, daughter)
mm/dd/yyyy
City of Birth Country of Birth
Country of Permanent Residence Country of Citizenship
Email address
Dependent 2
Name /
Family / Last Name Given / First Name and Middle Name
Date of Birth Relationship to visitor (son, daughter)
mm/dd/yyyy
City of Birth Country of Birth
Country of Permanent Residence Country of Citizenship
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