Cordell Hull Foundation SCHOOL NAME ________________________________ 2017-2018 School TEACHER ROSTER Year Country Elem or No Last Name Name Email address School name, Birth Date City Yearly 1st, Country Secondary? of 2nd or Birth address, zip Birth Subject (EXACTLY AS ON Mo-Day-Yr Salary 3rd yr code Taught PASSPORT) 1 2 3 4 5 6 7 8 9 RELATIVES: If spouse already has a visa, and children or spouses are not listed below, note here what type of visa the teacher currently holds. Last Name Middle Teacher Birth Date City Country Country Relationship to Note to School: Birth of Name Name Birth Please fill out this form in its Residence entirety. All information is (EXACTLY AS SHOWN needed to process the J-1 VISA ON PASSPORT) papers. The boxes in the lower portion of the form are for 1 accompanying relatives, who need a separate DS-2019 form 2 for J-2 visas. 3 4 Name and address of State representative or sponsoring Confucius Institute Indiana Department of Education, Chris Kates (ckates@doe.in.gov), 115 W. Washington St., South Tower, Suite 600, Indianapolis, IN 46204 Primary Building/District Contact Name and Address: __________________________________________________________________________
TEACHER ROSTER Cordell Hull Foundation SCHOOL NAME ________________________________ 2017-2018 School Year No Last Name Name (EXACTLY AS ON PASSPORT) Email address School name, address, zip code 1st, 2nd or 3rd yr Birth Date Mo-Day-Yr City Birth Country Birth Country of Residence Elem or Secondary? Subject Taught Yearly Salary 1 2 3 4 5 6 7 8 9 RELATIVES: If spouse already has a visa, and children or spouses are not listed below, note here what type of visa the teacher currently holds. Last Name Name Middle Name Relationship to Teacher Birth Date City Birth Country Birth Country of Note to School: Please fill out this form in its entirety. All information is needed to process the J-1 VISA papers. The boxes in the lower portion of the form are for accompanying relatives, who need a separate DS-2019 form for J-2 visas. (EXACTLY AS SHOWN ON PASSPORT) 1 2 3 4 Name and address of State representative or sponsoring Confucius Institute Indiana Department of Education, Chris Kates (ckates@doe.in.gov), 115 W. Washington St., South Tower, Suite 600, Indianapolis, IN 46204 Primary Building/District Contact Name and Address: __________________________________________________________________________
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