DS-2019 Certificate of Eligibility for Exchange Visitor (J-1) St

U.S. Department of State

OMB APPROVAL NO.1405-0119

CERTIFICATE OF ELIGIBILITY FOR EXCHANGE VISITOR (J-1) STATUS

EXPIRES: 07-31-2011
ESTIMATED BURDEN TIME: 45 min
*See Page 2

First Name:

1. Family Name:

Beauregard
Date of Birth (mm-dd-yyyy) :

06-12-1975

City of Birth:

Citizenship Country Code:

Country of Birth:

Lyon

FR

FR

FRANCE
Position Code:

Legal Permanent Residence Country Code: Legal Permanent Residence Country:
Primary Site of Activity:

Gender:

Middle Name:

Bonita

115

FRANCE
1000 Main St.
Fairfax, VA 20108

FEMALE

N0000136537

Citizenship Country:

FRANCE

J-1

Position:

PROFESSIONALS AND SCIENTISTS IN CENTRAL
GOVERNMENT

Exchange Visitor Program Number:

2. Program Sponsor:

G-5-13782

Sujata's June 11th
Participating Program Official Description:

PROFESSOR; RESEARCH SCHOLAR; STUDENT ASSOCIATE; STUDENT BACHELORS; STUDENT DOCTORATE; STUDENT
INTERN; STUDENT MASTERS; STUDENT NON-DEGREE
tcomments

Purpose of this form:

Replace a DS-2019 form (Damaged)
4. Exchange Visitor Category:

3. Form Covers Period:
From (mm-dd-yyyy) :
To

(mm-dd-yyyy) :

RESEARCH SCHOLAR

01-12-2009

Subject/Field Code:

12-31-2012

Subject/Field Code Remarks:

26.0907

None at this time.

5 . During the period covered by this form, the total estimated financial support (in U.S. $) is to be provided to the exchange visitor by:

Current Program Sponsor funds : $25,000.00
Personal funds : $2,500.00
Total : $27,500.00

Sample
6. U.S. DEPARTMENT OF STATE / DHS USE OR CERTIFICATION BY
RESPONSIBLE OFFICER OR ALTERNATE RESPONSIBLE OFFICER
THAT A NOTIFICATION COPY OF THIS FORM HAS BEEN PROVIDED
TO THE U.S. DEPARTMENT OF STATE ( INCLUDE DATE).

7.

Responsible Officer

mummy mohanty

Name of Official Preparing Form

address1
address2
city, DC
20001
Address
of Responsible Officer or Alternate Responsible Officer

Title

454-454-4354
Telephone Number

01-12-2009
Date (mm-dd-yyyy)

Signature of Responsible Officer or Alternate Responsible Officer

8. Statement of Responsible Officer for Releasing Sponsor (FOR TRANSFER OF PROGRAM)
Effective date (mm-dd-yyyy) :
. Transfer of this exchange visitor from program number
sponsored by
to the program specified in item 2 is necessary or highly desirable and is in conformity with the objectives of the Mutual Educational and Cultural Exchange Act of 1961, as amended.

Date (mm-dd-yyyy) of Signature

Signature of Responsible Officer or Alternate Responsible Officer

TRAVEL VALIDATION BY RESPONSIBLE OFFICER

PRELIMINARY ENDORSEMENT OF CONSULAR OR IMMIGRATION OFFICER REGARDING SECTION 212(e) OF THE
IMMIGRATION AND NATIONALITY ACT AND PL 94-484, AS AMENDED (see item 1(a) of page 2).

(Maximum validation period is 1 year*)

The Exchange Visitor in the above program:
1.

Not subject to the two-year residence requirement.

2.

Subject to two-year residence requirement based on:
A.

Government financing and/or

B.

The Exchange Visitor Skills List and/or

C.

PL 94-484 as amended

*EXCEPT: Maximum validation period is up to 6 months for Short-term
Scholars and 4 months for Camp Counselors and Summer Work/Travel.

(ALL USAID PARTICIPANTS G-2-00263 AND ALL ALIEN
PHYSICIANS SPONSORED BY P-3-04510 ARE SUBJECT TO
THE TWO-YEAR HOME RESIDENCE REQUIREMENT )

(1) Exchange Visitor is in good standing at the present time

Date (mm-dd-yyyy)

Signature of Responsible Officer or Alternate Responsible Officer
(2) Exchange Visitor is in good standing at the present time

Name

Title

Date (mm-dd-yyyy)
Signature of Consular or Immigration Officer

Date (mm-dd-yyyy)

THE U. S. DEPARTMENT OF STATE RESERVES THE RIGHT TO MAKE FINAL DETERMINATION REGARDING 212 (e).

Signature of Responsible Officer or Alternate Responsible Officer

EXCHANGE VISITOR CERTIFICATION: I have read and agree with the statement in item 2 on page 2 of this document.

Signature of Applicant

DS-2019
07-2008

Place

Date (mm-dd-yyyy)

Page 1 of 2

INSTRUCTIONS FOR AND CERTIFICATION BY THE ALIEN BENEFICIARY NAMED ON PAGE 1 OF THIS FORM:

Read this page and sign the Exchange Visitor Certification block on the bottom of page1 and prior to presentation to a United States Consular
or Immigration Official.
1. I understand that the following conditions are applicable to exchange visitors:
(a)

TWO-YEAR HOME-COUNTRY PHYSICAL PRESENCE REQUIREMENT (SECTION 212(e) OF THE IMMIGRATION AND NATIONALITY ACT AND PL 94-484,
AS AMENDED):
RULE: Exchange visitors whose programs are financed in whole or in part, directly or indirectly by either their government or by the U.S. Government, are required to reside in their
home-country for 2 years following completion of their program before they are eligible for immigrant status, temporary worker (H) status, or intracompany transferee (L) status.
Likewise, if exchange visitors are acquiring a skill that is in short supply in their home country (these skills appear on the "Exchange Visitor Skills List") they will be subject to the
same two-year home-country residence requirement. The requirement also is applicable to alien physicians entering the United States to receive graduate medical education or training.
The U.S. Department of State reserves the right to make the final determination regarding 212(e).
NOTE: MARRIAGE TO A U.S. CITIZEN OR LEGAL PERMANENT RESIDENT. OR BIRTH OF A CHILD IN THE UNITED STATES DOES NOT REMOVE THIS
REQUIREMENT.

(b) Extension of Stay/Program Transfers:

A completed Form DS-2019 is required in order to apply for a program extension or program transfer, and must be obtained from or with

the assistance of the sponsor.

(c)

Limitation of Stay: STUDENTS - as long as they pursue a full course of study towards a degree, or if engaged full-time in a non-degree program, up to 24 months. Students for
whom the sponsor recommends academic training may be permitted to remain for an additional period of up to 18 months after receiving their degree or certificate; post-doctoral
academic training may be approved by the sponsor for a period not to exceed 36 months; SECONDARY STUDENTS - up to 1 academic year; TRAINEES - 18 months; FLIGHT TRAINEES
- 24 months; TEACHERS - 3 years; PROFESSORS and RESEARCH SCHOLARS - 5 years; SHORT-TERM SCHOLARS - 6 months; SPECIALISTS -1 year; INTERNATIONAL VISITORS - 1 year;
ALIEN PHYSICIAN - the time typically required to complete the medical specialty involved but limited to 7 years with the possibility of extension if approved by the U.S. Department
of State; GOVERNMENT VISITOR - up to 18 months; CAMP COUNSELOR- up to 4 months; SUMMER WORK/TRAVEL - up to 4 months; AU PAIR- 1 year ; INTERN - up to 12
months.

(d)

Documentation Required for Admission/Readmission as an Exchange Visitor: To be eligible for admission to the United States, an exchange visitor must present the
following at the port of entry: (1) a valid nonimmigrant visa, unless exempt from nonimmigrant visa requirements; (2) a passport valid for 6 months beyond the anticipated period of
admission, unless exempt from passport requirements; (3) a properly executed Form DS-2019 (with 2-D barcode), which must be retained by the exchange visitor for readmission
within the period of previously authorized stay. Exchange visitors are permitted to travel abroad and maintain status (e.g., obtain a new visa) under duration of the program as
indicated by the dates on this form (see item 3 on page 1 of this form).

(e)

Change of Visa Status: Exchange visitors (and dependents) are expected to leave the United States upon completion of their program objective. Exchange visitors who are
subject to the two-year home-country physical presence requirement are not eligible to change their status while in the United States to any other nonimmigrant category except, if
applicable, that of official or employee of a foreign government(A) or an international organization(G) or member of the family or attendant of either of these types of officials or
employees.

(f)

Insurance: Exchange visitors are required to have medical insurance in effect for themselves and any accompanying spouse and minor children on J visas for the duration of their
exchange program. At a minimum, insurance coverage shall include: (1) medical benefits of at least U.S. $50,000 per person per accident or illness; (2) repatriation of remains in the
amount of U.S. $7,500; and (3) expenses associated with medical evacuation in the amount of U.S. $10,000. A policy secured to fulfill the insurance requirements shall not have a
deductible that exceeds U.S. $500 per accident or illness, and must meet other standards specified in the Exchange Visitor Program regulations, 22 CFR Part 62.14. For details, consult
your program's Responsible Officer or Alternate Responsible Officer (see item 7 on page 1 of this form).

2. EXCHANGE VISITOR CERTIFICATION: I have read and understand the foregoing, including the Two-Year Home-Country Physical Presence
Requirement, and agree to comply with the Exchange Visitor Program regulations, as amended (22 CFR Part 62). I certify that all the information on
the Form DS-2019 is true and correct to the best of my knowledge. I agree that I will maintain compliance with the insurance regulations as specified
in 22 CFR 62.14, including maintaining health insurance coverage for myself and my J-2 dependents throughout my J-1 program. I understand that
it is my responsibility to maintain my exchange visitor status. For the purposes of 20 U.S.C. 1232g and 22 CFR 62, I authorize the U.S.
Department of State-designated sponsor and any educational institution named on the Form DS-2019 to release information to the U.S. Department
of State relating to compliance with Exchange Visitor Program regulations.

NOTICE TO ALL EXCHANGE VISITORS

To facilitate your readmission to the United States after a visit in another country other than a contiguous territory or adjacent islands, you should have the
Responsible Officer or Alternate Responsible Officer of your sponsoring organization indicate on the TRAVEL VALIDATION BY RESPONSIBLE
OFFICER or Alternate Responsible Officer section of the Form DS-2019 that you continue to be in good standing.
The signature of the Responsible Officer or the Alternate Responsible Officer on the Form DS-2019 is valid for up to one year* or until the end date in item 3
on page 1 of this Form, or to the validation date authorized by the Responsible Officer, whichever occurs sooner.
*EXCEPT: Maximum validation period is up to 6 months for Short-term Scholars and 4 months for Camp Counselors and Summer Work/Travel.

* Under the Mutual Educational and Cultural Exchange Act of 1961, as amended, the U.S. Department of State has been delegated the authority to designate Exchange Visitor
Programs for U.S. Government agencies, and for public and private educational and cultural exchange organizations. The information is used by Exchange Visitor Program sponsors
to appropriately identify an individual seeking to enter the United States as an exchange visitor. The completed form is sent to the prospective exchange visitor abroad, who takes it
to the U.S. Consulate (Embassy) to secure an exchange visitor (J-1, J-2) visa. Responses are mandatory. An Agency or organization may not conduct or sponsor, and the respondent
is not required to respond to a collection of information unless it displays a valid OMB control number. Public reporting burden for this collection of information is estimated to
average 45 minutes per response, including the time for reviewing instructions, researching existing data sources, gathering and maintaining the data needed, completing and
reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden to: U.S. Department of State, A/ISS/DIR, Washington, D.C. 20520.
DS-2019
07-2008

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