Section 1: Personal Academic/Work Information

Enter full name in the fields below as it appears in your passport:
Exception: If you have only one name, please provide it in the Surname/Family Name field
* Surname/Family name:
Given name or names:
Middle name(s):
* Date of birth:        
* Country of birth:
* Your current nonimmigrant status:
* Who issued your visa documents? Duke
ECFMG
Other
* Duke Unique ID: 
To find your Duke Unique ID, go to https://dukeid.duke.edu:8882/emailalias/owa/publicsearch.
If you do not have a Duke Unique ID, please contact your department to have one assigned and check this statement: 		I do not have a Duke Unique ID, but I will request one.
* Duke e-mail address:
Please use a Duke e-mail, not a private vendor address such as “hotmail” or “aol.”
If you do not have a Duke e-mail address please contact your department to have one assigned and check this statement:   I do not have a Duke email address, but I will request one.
Non-Duke e-mail address:


* Duke enrollment status: 
I am currently a student enrolled at Duke AND I am working at Duke:
I am currently a student enrolled at Duke. I am not working at Duke.
I am not a Duke Student. I am currently an employee, trainee, or visitor at Duke.
I am currently on Duke Sponsored Post-Degree F-1 OPT or J-1 Academic Training


The U.S. local residential address that you are reporting/updating:
Address Line 1:
Address Line 2:
City:
State:
Zip code:  - 
  (go to usps.com to find your ZIP+4 code)
Phone:  (999) 123-4567
Pager:  (999) 123-4567
Cell Phone:  (999) 123-4567
Work Phone:  (999) 123-4567
Fax:  (999) 123-4567

If you are an F-1 student on Optional Practical Training or a J-1 student on Academic Training, the U.S. Department of Homeland Security requires you to report your employer's name and address.

* Major Field of Study at Duke Was:

Employer Name:
Employer Address Line 1:
Employer Address Line 2:
Employer City:
Employer State:
Employer Zip code:  - 
  (go to usps.com to find your ZIP+4 code)

 

If you are not in J-1 status, then SKIP to Section III: Affirmation of Accuracy”.

If you are in J status, then you must complete Section II: J Exchange Visitor Insurance Verification.

Section II: J Exchange Visitor Insurance Verification

Read the insurance requirements at http://www.internationaloffice.duke.edu/J_Medical_Insurance.htm

After you have read the insurance requirements, answer these questions.

1. Do you have health insurance for yourself and all of your J-2 dependents that meets the requirement? Yes No

2. Do you have medical evacuation insurance for yourself and all of your J-2 dependents that meets the requirement? Yes No

3. Do you have repatriation of remains insurance for yourself and all of your J-2 dependents that meets the requirement? Yes No

If you answered “no” to any of these questions, please contact International House immediately (684-3585) to discuss how to obtain proper insurance.Willful failure to maintain the required health, medical evacuation, and repatriation of remains insurance for you and your dependents is a violation of your J Exchange Visitor status and can terminate your participation in the program.

Section III: Affirmation of Accuracy

Read and affirm this statement. “By this submission I confirm that the information I have entered is true, complete, and correct..”
*Check here to confirm ->



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