J-1 Fellowship/Visa Information

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J-1 Fellowship/Visa Information

This form is used to collect much of the relevant information neccessary as we initiate your fellowship with the Center for Global Health. Please complete the form and let us know if you have questions.

Last Name:

(Surname, exactly as it appears on your passport)

First Name:

(Given name, exactly as it appears on your passport)

Middle Name:

Email Address:

Primary and secondary email address if available, separated by commas.

Current Institutional Affiliation:

(i.e. Federal University of Ceara, Makerere University, etc.)

Position and/or title in country of legal permanent residence:

(i.e. Associate Professor, Research Fellow, Medical Student)

Current Degree:

(i.e., PhD. MD, Msc.):

Male

Female

Date of Birth (MM/DD/YYYY):

City of birth:

Country of birth:

Country of legal permanent residence:

Country of citizenship:

The date you plan to come to the US to begin your fellowship:

The date that you plan to leave:

Research Activities Abstract:

In the field below, please upload a one (1) page planned research summary including title, background, objectives, methods, expected output and timetable of actvitities. This is intended to be a brief abstract for use in obtaining your visa.

Please upload a copy of your current CV in English:

Please upload a scanned copy of your passport face page:

Please upload a picture of yourself:

Additional Comments:

Medical information in case of emergency:

(i.e. allergies, diabetes, etc.)

Emergency Contact in your home country:

Whom should we notifiy in the event of an accident or problem? Please provide email, address and telephone (with country and city code)

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J-2 Dependents:

If spouse, children or other dependents will accompany you on a J-2 visa, please enter their information below. Please send data for additional J-2 dependents to ctrglobalhealth@virginia.edu.

Last Name:

(Surname, exactly as it appears on the passport):

First Name:

(Given name, exactly as it appears on the passport)

Middle Name:

Date of birth (MM/DD/YY):

Male

Female

City of birth:

Country of birth:

Country of citizenship:

Country of legal residence:

Relationship (spouse or child):

J-1 Fellowship/Visa Information

J-1 Fellowship/Visa Information

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