Research Corporation of the University of Hawaiʻi

Research Corporation
of the University of Hawai‘i
Human Resources Department
J-2 INFORMATION FORM
The J-1 exchange visitor (EV) must complete and submit this form for any dependents (spouses and/or unmarried children under 21 years old) and request for J-2 status. EV is responsible for his/her J-2 dependents while they are in the U.S. Please provide a copy of Passport and Proof of Relationship document (e.g., marriage certificate, birth certificate, etc.)
Dependent 1
Dependent 2
Dependent 3
Acknowledgement of Exchange Visitor:
EV is responsible for the following requirements for his/her J-2 dependent(s):
 Financially supporting his/her J-2 dependents while they are in the U.S.
 Required to have the medical, evacuation and repatriation insurances coverage for his/her J-2 dependents.
 Inform RCUH Human Resources if any accompanying spouses and/or dependents depart from U.S. prior to the exchange’s
visitors’ departure dates.
 Inform RCUH Human Resources for any personal information changes (e.g., address, phone number, email, etc.).
 Inform RCUH Human Resources for any loss or theft of Forms DS-2019.
______________________________________________________________ _________________________ Exchange Visitor (Signature) Date
_______________________________________________________________ Exchange Visitor (Print Name)
RCUH Form I‐110
Created 12/14 (Revised 04/16, 10/16)
1. Name on Passport (Last Name, First Name, Middle):
2. Gender:
Male
Female
3. Date of Birth (mm/dd/yyyy):
4. Relationship:
Spouse
Child
5. Email:
6. Nationality:
a. City of Birth:
b. Country of Birth:
c. Country of Citizenship
d. Country of Legal Permanent Residence:
1. Name on Passport (Last Name, First Name, Middle):
2. Gender:
Male
Female
3. Date of Birth (mm/dd/yyyy):
4. Relationship:
Spouse
Child
5. Email:
6. Nationality:
a. City of Birth:
b. Country of Birth:
c. Country of Citizenship
d. Country of Legal Permanent Residence:
1. Name on Passport (Last Name, First Name, Middle):
2. Gender:
Male
Female
3. Date of Birth (mm/dd/yyyy):
4. Relationship:
Spouse
Child
5. Email:
a. City of Birth:
b. Country of Birth:
c. Country of Citizenship
d. Country of Legal Permanent Residence: