Research Corporation of the University of Hawaiʻi

Research Corporation
of the University of Hawai‘i
Human Resources Department
Type of J-1 request:
J-1 REQUEST FORM
Initial J-1 (new employee is outside the U.S. and will enter in J-1 status)
Change of Status (person is in U.S. and will change to J-1 from a different visa status)
J-1 Transfer (person is currently in J-1 status and will change from another J-1 program to RCUH) Extension
Part I: Biographical & Immigration Information 1. Name on Passport (Last Name, First Name, Middle): 2. Gender: Female
3. Date of Birth (mm/dd/yyyy)
4. Nationality
City of Birth:
Country of Birth:
Country of Citizenship:
Country of Legal Permanent Residence:
5. Foreign Home Address Street Address:
City:
Country: Province/Territory: Postal Code:
6. Foreign Mailing Address (if different from Home Address) Street Address:
City:
Country:
Province/Territory:
Postal Code:
7. Telephone #:
8. Email:
9. Emergency Contact in Home Country
Name: Relationship: Address: Phone #:
10. Position in Home Country (i.e., Job Title):
11. If already in the United States, please provide the following information.
a. Last Date of Arrival:
b. I-94# (attach copy):
c. Current Nonimmigrant Status:
d. Expiration Date:
e. Residential address in the US:
f. If there are future travel plans for travel outside of the U.S., please list the destination and dates of departure & return*:
*Note: Individuals filing for a change of status to J-1 should not leave the U.S. once the RCUH files the petition with the service center if the approval is not received.
RCUH Form I-104
Created 10/05 (Revised 11/10, 11/13, 12/14, 01/15, 04/16, 10/16)
Male

J-1 Request Form Page 2 of 4
12. If this person is already in the United States, does this person have immediate family members which require change in their current Nonimmigrant status? Yes No
If yes, complete the J-2 Dependent Information Form.
13. Is this person currently in removal (deportation) proceedings? Yes No
14. Has this person previously held J-1 or J-2 status? Yes No If yes, please provide dates of J-1 status and copies of previous Form(s) DS-2019.
15. Is this person subject to the two-year home country residence requirement? Yes No
16. Street Address in U.S. (or expected/temporary address):
17. Has this person previously been in the U.S.? Yes No If yes, provide history of dates and visa status.
Part II: Position Information
18. Position Title:
19. Intended J-1 period:
20. Address of the Primary Site of Activity
Street Address: City:
State:
Zip Code:
21. Address(es) of any Additional Sites of Activity Street Address:
City:
State:
Zip Code:
22. Name of Principal Investigator:
Phone #:
Email:
23. Name of Supervisor:
Phone #:
Email:
24. Estimated amount of financial support which will be provided for the entire appointment period
a. Salary/Wages: $
b. Housing: $
c. Other (explain in comments section): $ TOTAL: $
25. Other financial Support:
a. U.S. Government Agency(ies): $
b. International Organization(s): $
c. The Binational Commission of the Exchange Visitor’s Country: $
d. The Exchange Visitor’s Government: $
e. Other organization(s) providing support (explain in comments section): $ f. Personal Funds: $
RCUH Form I-104
Created 10/05 (Revised 11/10, 11/13, 12/24, 01/15, 04/16, 10/16)

J-1 Request Form Page 3 of 4
26. Has your project received funding for international exchange from one or more U.S. Government agency(ies) to support this exchange visitor?
No
Yes. If yes, provide name of agency(ies):
27. Check the appropriate J-1 category: (Check one) Research Scholar: Duration 3 weeks up to 5 years. Short-term Scholar: Duration 1 day up to 6 months. Specialist: Duration 3 weeks up to 1 year.
28. Project FedEx account #:
29. Comments:
Part III: Instructions
The J-1 Request Form & the Pre-Arrival and Orientation Information for J-1 Exchange Visitors – Certificate of Awareness & Understanding must be submitted to RCUH Human Resources at least six (6) weeks prior to the requested effective date.
The following documents must also be submitted:
30. Copy of valid passport and I-94 card.
31. Proof of required medical, evacuation, and repatriation insurance. (Refer to Pre-Arrival and Orientation Information
for Exchange Visitors for options.)
32. Signed offer letter from the Principal Investigator & EV which includes:
a. Program activities
b. Cultural goals and components of the program
c. Employment of information and terms and conditions of employment, including:
i. Employer name and address ii. Position duration
iii. Job duties (provide a copy of job description) iv. Number of work hours
v. Wages
vi. Other compensation and benefits (refer to RCUH New Hire Reference Guide)
vii. Deductions from wages, including those taken for housing and transportation (refer to RCUH Pre- Arrival and Orientation Information for J-1 Exchange Visitor)
d. Description of the temporary nature of the position
e. Confirmation that intent of the person is to return to home country when the J-1 program ends.
33. Resume.
34. Copies of academic degree(s).
35. Proficiency in English language: Participants must possess sufficient proficiency in the English language, as
determined by an objective measurement of English Proficiency, successfully to participate in their programs and to function on a day-to-day basis [22 CFR 62] Projects are required to use one of the following “objective measurements of English language proficiency” to determine an applicant’s language proficiency:
a. a recognized English language test;
b. signed documentation from an academic institution or English language school; or
c. a documentation interview conducted by the sponsor either in-person or by videoconferencing, or by
telephone if videoconferencing is not a viable option
36. Copies of previous Forms I-797, DS-2019, I-20 (if applicable).
RCUH Form I-104
Created 10/05 (Revised 11/10, 11/13, 12/24, 01/15, 04/16, 10/16)

J-1 Request Form Page 4 of 4
Part IV: Acknowledgement of Exchange Visitor
I have read the RCUH Pre-Arrival and Orientation Information and RCUH New Hire Reference Guide for J-1 Exchange Visitors. I understand and will abide by all requirements of the RCUH J-1 Exchange Visitor Program. I attest that I meet all of the stated requirements for the RCUH J-1 Exchange Visitor Program. I attest that the information provided to you is accurate to the best of my knowledge. I further understand that falsification of information and failure to abide by the RCUH J-1 Exchange Visitor Program rules may result in the termination of my visa, program, and employment with RCUH. I understand that my participation in the RCUH J-1 Exchange Visitor Program is not an employment contract or any other type of contract between myself and RCUH. I further understand that my program can be modified or cancelled at any time, if deemed appropriate by the RCUH.
_______________________________________________________________ _________________________ Exchange Visitor (Signature) Date
_______________________________________________________________ Exchange Visitor (Print Name)
Part V: Principal Investigator Certification
I certify that I have sufficient funding to support this action and related costs.
_______________________________________________________________ _________________________ Principal Investigator (Signature) Date
_______________________________________________________________ Principal Investigator (Print Name)
Project person responsible for the coordination of this action:
Name: ___________________________________________
Phone #: _________________________________________ Email: ___________________________________________
Part VI: RCUH Human Resources Visa Request Approval
_________________________________________________________ __________________________ Director of RCUH HR or Designee Date
RCUH Form I-104
Created 10/05 (Revised 11/10, 11/13, 12/24, 01/15, 04/16, 10/16)