ࡱ> PRO%` +bjbj"x"x 4.@@$ < $8h0 `0\07777777$9hU<7QAAA7?8A 7A7nd47$ P@ K.l5 7U8085M=y.M=@7M=7Z@V477 8AAAA$$$$H $$$H $$$ Request for DS-2019 for J-1 Intern: Please provide name of prospective intern, as it appears on the passport. Family Name:  FORMTEXT       Given Name:  FORMTEXT       Middle Name:  FORMTEXT       Date of Birth:  FORMTEXT   / FORMTEXT   / FORMTEXT      Gender  FORMCHECKBOX  Male  FORMCHECKBOX  Female mo/day/yr E-mail address:  FORMTEXT       Highest degree earned and area of study:  FORMTEXT       Name of institution where the intern studies in their home country:  FORMTEXT       Level of study:  FORMTEXT       What dates would you like to have the internship run?  FORMTEXT   / FORMTEXT   / FORMTEXT      to  FORMTEXT   / FORMTEXT   / FORMTEXT      mo/day/yr mo/day/yr Please briefly describe the internship:  FORMTEXT       How will intern be funded for their time in the U.S.?  FORMTEXT       *Please note: Intern will also need to include proof of insurance to cover you in the U.S. during your visit. Hosting Department, please attest to the following: I have determined that the student is proficient in English by: ___ Interview conducted by the sponsoring department ___ Documentation provided by the student from an English Language program ___ TOEFL or other test score I understand that this Exchange Visitor J-1 intern will not be eligible to live on campus. I will assist this intern in finding appropriate housing for their stay and in becoming oriented to the ƵChicago community. 0FJLhr   " $ 8 < > R T V ` b d z ~ ȽȯȽȐȽȂ{wpi{ h# h-Q h# h`Hh} h# h}jh# h# Ujvh# h# U jh# h^`UmHnHujh# h# Ujh# h^`U h# h^` h# hF h}^J h(x^Jh^`hD(vCJ h^`5 h_55 h<5 hyV5)HJL   4 {{ 7$8$H$gd} & F hh7$8$H$^hgd^` 7$8$H$gdR & F h07$8$H$`0gd#  hP7$8$H$gd} & F hPh7$8$H$^hgd^` P]gd^`gd^` +      $ & ( 0 2 4 @ D F b d f t v xof` h}CJh# h}CJhF h# ^Jj8h}h# U^Jjh}h# U^Jjh# U^J h# ^J h(x^Jh# jNh^`h}Ujh^`h}U jh^`h}UmHnHujbh^`h}U h^`h}jh^`h}U$     V Z \ p r t ~   " $ & 0 2 4 R V X l n p z | ~ ظظظvظp h-Q^Jjh}h# U^Jjh}h# U^J h`H^J hR^J he^Jj"h}h# U^Jjh}U^JmHnHujh}h# U^Jjh}U^JhF h-Q^J hF ^JhRh}CJ h}^J,4 6 ~ z|,-vmm 7$8$H$gd# h7$8$H$^hgd@C h7$8$H$^hgdK & F hh7$8$H$^hgdP2 xP8^8gdR & F hxPh^hgde 7$8$H$gd} & F hh7$8$H$^hgd^` h7$8$H$^hgd`H ~      $ & ( , . 0 2 F H J R T V X \ ^ r t v z | ~ ٬ٌٞٚ~pjh^`h}Uj\h^`h}Ujh^`h}Uh}jph^`h}Ujh^`h}U jh^`h}UmHnHujh^`h}U h^`h}jh^`h}U h}^J he^JhF h}^J, 0FHLNPdfhrtxz| ýñ{uoiYjh}h# U^J hXfe^J ho^J hK^J h-Q^Jjh}U^JmHnHujHh}h# U^Jjh}U^J h}^J hQ#^J h`H^J h(x^J h\^J hR^J heCJ h}CJh}h}^Jjh^`h}U jh^`h}UmHnHu :+,=?&&&'''''(X)|)))T*\*^*`**** ++B+D+F+j+v++++ûΰîΛλ}λ}}λ}haB*phh{hRB*ph h{hRhRheB*phhqhKB*phUhohoB*phhRB*phhqhoB*phhoB*ph he^J hR^J h ^J hdF^J hK^J ho^J hP2^J0-m''^*`***l+n++ 7$8$H$gdR 7$8$H$gdo h7$8$H$^hgdo 7$8$H$gd# I agree to provide the supervision required for this intern and to conduct the required evaluation(s) of this intern and to provide copies of the evaluation(s) to International Student and Scholar Services. I understand the J-1 intern must work a minimum of 32 hours a week and only 20% can be clerical. The internship must be the primary purpose of their visit to the US and that the intern may not be involved in clinical or patient care. The internship can be paid or unpaid. See regulatory information on the (J Student Intern Practice Advisory). Host Faculty Signature________________________ Date_____________ Department Chair Signature____________________ Date_____________ Dean s Signature_____________________________ Date_____________ ++hRheB*ph21h:pR/ =!"#$% vDText50vDText51vDText52vDText47vDText48vDText49tDeCheck3tDeCheck4vDText58vDText59vDText60vDText61vDText44vDText45vDText46vDText47vDText48vDText49vDText64vDText65@@@ NormalCJ_HaJmH sH tH DA@D Default Paragraph FontRi@R  Table Normal4 l4a (k@(No Listj@j # Table Grid7:V0 . $%&pS_?@=>,-m/0tu000 000 00 00 00 00 00 00 00 000000000000000000000$%&pS_?@=>/000 000 00 00 00 00 00 00 0 0 0 000 0 0Z000Z00  ~ ++ 4 -+ + ~"2:Jo{+7=v'39tFFFFFFG$G$FFFFFFFFFFFF Text50Text51Text52Check3Check4Text58Text59Text60Text61Text64Text65#;p,(u 3K>:$ $ $ $$ $$ \p$ tnnuurrwwB*urn:schemas-microsoft-com:office:smarttagscountry-region9*urn:schemas-microsoft-com:office:smarttagsplace $ T]t33T@0 IY*}8d+ʃV,0d7[0OrJvdF>K-QyVaXfeqD(v(x[{K:_5} @C`HDQ#kCKRe8>N f^`0@8L  @&UnknownG: Times New Roman5Symbol3& : Arial5& zaTahoma?5 z Courier New;Wingdings"hzզi{զzզ VV!24d 2QHX)?-Q24Procedures for Exchange Visitors  Visiting ScholarsInformation ServicesInformation Technology Services@         Oh+'0 $8 `l    8Procedures for Exchange Visitors Visiting ScholarsInformation Services Normal.dot Information Technology Services9Microsoft Office Word@40@~@\y@FV՜.+,04 hp  ƵChicago' 5Procedures for Exchange Visitors Visiting Scholars Title !"#$%&'()*+,-./0123456789:;<=>@ABCDEFHIJKLMNQRoot Entry F ⼽SData 1Table =WordDocument4.SummaryInformation(?DocumentSummaryInformation8GCompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q