| Family name: |
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| First Name: |
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| Middle Name(s): |
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| Gender: |
Male
Female |
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| Current address: |
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| e-mail: |
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| Telephone no.: |
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| Date of birth: |
Year
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| City of birth: |
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| Country of birth: |
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| Country of permanent residency: |
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| Country of citizenship: |
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Title of current position in home country:
(i.e. undergraduate student, professor, etc.) |
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| Name of employer in home country (if applicable) |
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Nature of employer:
(i.e. national government, local government, nonprofit, private industry, etc.) |
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Estimated beginning date of J-1 program
(If unknown please leave blank):
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Year
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| Estimated ending date of J-1 program: |
Year
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| J-1 category: |
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| ________________________________________________________________________________________ |
| Explanation of the various J-1 categories: |
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| 1) Student Masters: Exchange visitor who will enrolled on a full-time basis in the Bowman Gray M.S. program |
| (Maximum time: No set time; exchange visitor allowed to remain in U.S. until degree is obtained) |
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| 2) Student Doctorate: Exchange visitor who will be enrolled on a full-time basis in the Bowman Gray Ph.D. program |
| (Maximum time: No set time; exchange visitor allowed to remain in U.S. until degree is obtained) |
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| 3) Research Scholar: Exchange visitor coming to WFUHS to conduct research, learn new techniques, etc. whose program will last for longer than six months |
| (Maximum time: Five years) |
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| 4) Short-Term Scholar: Exchange visitor coming to WFUHS to conduct research , observe, learn new techniques, etc. whose program will not last longer than six months |
| (Maximum time: Six months) |
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| Important: Please be aware of the fact that a short-term scholar program cannot be extended beyond six months; if you feel that there is even a slight chance that your program will go beyond six months, please select the "research scholar" category |
| ________________________________________________________________________________________ |
| Department at WFU Health Sciences that has agreed to sponsor you for your J-1 program: |
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| Name of contact person in sponsoring department: |
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| Please provide a brief description/summary of the research activities you will be conducting at WFUHS: |
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| Note: It is necessary that you provide a monetary amount for the funding information of your program. This amount can be an estimate. If you list the amount in a currency other than the US$, please note the type of currency. |
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| Total amount of financial funding/benefits provided by Wake Forest Health Sciences:
(salary, food, housing, scholarship, etc.) |
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| Financial support coming from source(s) other than Wake Forest Health Sciences: |
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| Name(s) of organization(s), other than WFUHS, who will provide funding: |
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| Additional information/comments: |
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| Within the past 24 months, have you been
physically present in the U.S. in either the J-1 or J-2 category
as a professor or research
scholar (does not apply to the short-term scholar category) for a period
of 6 months or longer? |
| Yes
No
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| Please explain: |
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| Dependent Information |
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| Will any dependents accompany you? |
Yes
No |
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| Please provide the following information for all dependents
who will accompany you:. |