J1 Waiver Questionnaire

1. Information about you

Name

First

Middle

Last

Other Names Used 1

First

Middle

Last

Other Names Used 2

First

Middle

Last

Alien Number (USCIS Number or A#)

I-94 Number

Social Security Number (SSN)

Current Address or Last US Address if Outside the US

Address Line 1

Address Line 2

City

State

Zip Code

Marital Status

Date of Birth

City / State / Country of Birth

Country of Citizenship

Country of Last Foreign Residence

List all Program Sponsors and Corresponding Program Numbers

Major Field of Activity

Occupation

Date of Last Entry to US with J1 Visa

Port of Entry of Last Arrival with J1 Visa

J1 Visa Issuing Post (Name of Embassy that Issued Your J1 Visa)

Date of Departure if you left the US

Last Address in the US, if not currently in the US

Address Line 1

Address Line 2

City

State

Zip Code

Did your exchange visitor program(s) include U.S. Government funds, funds from your own government or funds from an international organization?

Is there any period of time in the US that is not covered by your form DS-2019

Explain Below

Have you ever applied for a J1 waiver before?

What was your case number for the prior application?

2. Information about your spouse

Name

First

Middle

Last

Date of Birth

City / State / Country of Birth

Country of Citizenship

Country of Last Foreign Residence

3. Information about your children

Name 1

First

Middle

Last

Date of Birth 1

Country of Birth 1

Country of Citizenship 1

Country of Last Foreign Residence 1

Name 2

First

Middle

Last

Date of Birth 2

Country of Birth 2

Country of Citizenship 2

Country of Last Foreign Residence 2

Name 3

First

Middle

Last

Date of Birth 3

Country of Birth 3

Country of Citizenship 3

Country of Last Foreign Residence 3

Name 4

First

Middle

Last

Date of Birth 4

Country of Birth 4

Country of Citizenship 4

Country of Last Foreign Residence 4

4. Enter the information of the person submitting this questionnaire.

Name *

Email *

J1 Waiver Questionnaire

For Exchange Visitors

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