Personal Information:

Last/Family Name

First Name

U.S. SSN/ITIN

Date of Birth (mm/dd/yy)

 

Current Visit Information:

Date of Arrival in U.S.
   
Expected Date of Departure

Passport issued by (country)
   
Passport Number

Passport Expiration Date

Current Visa Type (B1, VWB, J1 non-student, Other

Visa #

What is the primary activity for this visit?  Teach, Lecture, Observe, Consult, Train, Research, Temporary Employment, Other

Do/will you have a permanent office (fixed base) in the U.S.?
 
If receiving an honorarium, is the activity to receive the honorarium to last for more than 9 days?

Did you receive an honorarium from more than 5 organizations in the prior 6 month period?

Country where you lived immediately before coming to the U.S. (tax residence)
 
Country of Citizenship

Have you applied for Permanent Residency?

Name of your contact at Wesleyan?

Address Information:

LOCAL Address (if applicable):
Street Number and Name

City, State, Zip

FOREIGN Residence Address:
Street Number and Name

City

Province/Region

Postal Code

Country

Email Address:

 

VERY IMPORTANT to Complete Past Entries/Visits to the U.S.:

Date of Entry      Date of Exit
Visa Type: F1, F2, J2, J1 student, J1 non-student, Other (explain)

Date of Entry      Date of Exit
Visa Type: F1, F2, J2, J1 student, J1 non-student, Other (explain)

Date of Entry      Date of Exit
Visa Type: F1, F2, J2, J1 student, J1 non-student, Other (explain)

Date of Entry      Date of Exit
Visa Type: F1, F2, J2, J1 student, J1 non-student, Other (explain)

 Date of Entry      Date of Exit
Visa Type: F1, F2, J2, J1 student, J1 non-student, Other (explain)