Middlebury College

International Student and Scholar Services

Carr Hall Middlebury, Vermont 05753
Telephone: 802-443-5858
Fax: 802-443-2063
Email: isss@middlebury.edu
Web: http://go.middlebury.edu/isss

International Faculty / Staff

Information Form

Office Use Only: Date Received: _______________Midd ID: _________________ NI Status: _______________ Role: ______________________
# of Weeks: _____ Salary: ____________ Room/Board Amt: ____________ Insurance: ____________ Total for DS-2019: __________________
J Dependents? Yes, # ____

No

Has a U.S. SSN?

Yes

No

DS-2019 dates: ______________________________________

Part 1. Location and School: Please check the appropriate box

Middlebury College, Middlebury
VERMONT:

Language Schools
Middlebury, VERMONT:

Language Schools
Mills College, Oakland, CALIFORNIA:

Entire Academic Year

Chinese School

Arabic School at Mills College

Fall Term

French School

French School at Mills College

Winter Term (January)

German School

Japanese School at Mills College

Spring Term

School of Hebrew

Spanish School at Mills College

Italian School

Bread Loaf School of English (BLSE):

M

Portuguese School

i
BLSE in Vermont
d
Russian School
BLSE in New Mexico
d
l
Spanish School
BLSE in North Carolina
e
b
Bread Loaf Writers Conference
u
(BLWC):
r
y
BLWC in Vermont
M
o
n
Part 2. Personal Information
Please
check:
FEMALE
MALE
t
e
r
HENRIQU
Name exactly as it appears in passport: ______________________________________________________________________
e
(Family)
(First)
(Middle)
y

SAYO CARNEIRO JORGE

Non-U.S. Permanent Address:

L
Address to which
ISSS documents should be sent:

Rua do Senado 84
_________________________________________________
Rio de Janeiro, RJ, Brazil
_________________________________________________
zip 20231000
_________________________________________________
_________________________________________________

a
via Carolina
n Coronedi Berti 3
____________________________________________________
g
Bologna, uEmilia-Romagna, Italia
____________________________________________________
a
g
zip
40137
____________________________________________________
e
A

39/333/8872758
Cell Phone Number:
_______________________________
c

Country Code / City Code / Number

a
d
e
m
Rio de Janeiroy
Brazil
Birth: _________________________
Country of Birth: ________________

jorgefrente@gmail.com
E-mail address: ____________________________________

august 18, 1962

Date of Birth: ________________________
City of
Please spell the month (i.e. January 1, 1990)

(
M
Italy
Country of Legal Permanent
Residence: ______________________
M
L
Do you have dependants (spouse or children) who will accompany youA to the U.S./Middlebury?
No
Yes
)
_
Will your partner / spouse also be employed by Middlebury this summer?
No
Yes
_
_
If yes, name of partner / spouse: _____________________________________________________________________________
_
W
i
n

Brazil
Country of Citizenship: ___________________

Part 3. Visa Related Information

3a. Are you currently in the U.S.?

No

Yes, until _____________

If yes, what is your current nonimmigrant status? _________________________________________________

(Such as: F-1, H-1B, J-1 Professor, J-1 Short-Term Scholar, J-1 Student)

If yes, please list/indicate current employer or institution: ___________________________________________

publisher
3b. Occupation in Home Country: _____________________________________________________________

frente editora ltda

Employer: _____________________________________________________________________________
If you are a teacher or a student, please indicate the type of school or program:
Teacher:

High School

College/University

Student:

3c. In the past two years, have you ever held J-1 or J-2 status?

Undergraduate

No Yes

Graduate

If yes, please list dates:

xxxxxxxxxxxxxxxxxxxxxxxx

___________________________________________________________________________________________________________

no
3d. If you have held J status before, are you subject to the 212(e) two year home residence requirement? __________
Have you ever received a waiver of this requirement from the Department of State?

No

Yes

3e. Is there a chance that you will wish to extend or transfer your J-1 program to another institution after your Middlebury
College contract?

No

Yes

If yes, to which institution?_____________________________________________________________

3f. Dependent Information (Only list family members if they will be applying for a dependant visa.)
LAST NAME First Name

Date
of Birth

City
of Birth

Country
of Birth

Country of
Citizenship

Country of
Residence

Relationship
(ex: Daughter)

__________________________

____________ ____________,____________ _______________ _______________ ___________

Mo Day Year

__________________________

____________ ____________,____________ _______________ _______________ ___________

If you have dependents applying for J-2 status, please also send:
___ Photocopy of biographical page of dependent(s) passport(s)
3g.

If you are currently in the U.S., please also send:

___ Copy (front and back) of your I-94 card (the small, white card stapled into your passport)
___ Copy of your current U.S. visa
___ Copy of your current DS-2019 if applicable, or other immigration document

Part 4. Statement from the Applicant

By checking these boxes, I certify that the information on this form and accompanying financial documents are accurate
.
and true.

I will return this form with a copy of the information page(s) of my passport.
____
I give ISSS my permission to mail my documents together with my partners/spouses as listed in Part 2, if
____
applicable.
Please sign or type below. A typed name serves as a signature for this electronic form.
___________________________________________________________________________________________________________________

Signature

Date (month/day/year)

Please Save As this form as your last name_first name.

Then e-mail it with a scanned copy of your passport identification page to:
isss@middlebury.edu
If you prefer, you can print and scan the form to the e-mail above, or mail it; please e-mail us for instructions.