Date(s) Awarded: U.S. Home Address Permanent Address outside the U.S. Phone: Area ( ) ( ) - Email: C. Dates of Appointment: From , To , (see Instructions) If in the U.S.: I-94 form No Expiration Date: , For extension, initial date of , D. Exchange Visitor's appointment or primary activity at UCLA: Visiting Professor Visiting Lecturer Visiting Researcher Guest Speaker Visiting Scholar Post Doctoral Scholar Other: Visiting Grad Researcher Subject of studies, research, or teaching at UCLA. (No more than 15 words) E. Financial Support for the entire period covered by this form. Specify amounts in US dollars UCLA: Department budget, grant, etc. Source: Payroll title: This is a non-tenure track position: Yes No U.S. Government agency funds to this Exchange Visitor: Name of the Agency: International Organization [e.g. UN, WHO, NATO] funds to this Exch. Visitor: Name of Organization(s): Exchange Visitor's Government. Name of the Agency: Other organizations/institutions in the U.S. or abroad:
Date(s) Awarded: U.S. Home Address Permanent Address outside the U.S. Phone: Area ( ) ( ) - Email: C. Dates of Appointment: From , To , (see Instructions) If in the U.S.: I-94 form No Expiration Date: , For extension, initial date of , D. Exchange Visitor's appointment or primary activity at UCLA: Visiting Professor Visiting Lecturer Visiting Researcher Guest Speaker Visiting Scholar Post Doctoral Scholar Other: Visiting Grad Researcher Subject of studies, research, or teaching at UCLA. (No more than 15 words) E. Financial Support for the entire period covered by this form. Specify amounts in US dollars UCLA: Department budget, grant, etc. Source: Payroll title: This is a non-tenure track position: Yes No U.S. Government agency funds to this Exchange Visitor: Name of the Agency: International Organization [e.g. UN, WHO, NATO] funds to this Exch. Visitor: Name of Organization(s): Exchange Visitor's Government. Name of the Agency: Other organizations/institutions in the U.S. or abroad:
Request-Certificate-Eligibility-for-J.docx