J-1 Sponsorship Extension Form Fill out this required form completely and carefully. You must return this form as a PDF to InternationalTeachers@iie.org. You may type or print clearly in ink. The signatures must be handwritten.
Part A:
Please provide the following information:
Name: _______________________________________________________________________________________ Given/First Middle Family/Last Date of Birth: ____ / ____ / ______ Passport Expiration Date: ____ / ____ / _____ Month Day
Year
Month
Day
Year
Current E-mail: _____________________________ Telephone/Cell Phone Number: ________________________ Current Address in the United States* (Please provide the actual physical Street
Apt. #
City
State
location where you reside):
Zip Code
*Please note that you are required by law to report to IIE any changes to your physical location address within 5 days of the move. Failure to report changes may result in termination of your J-1 Visa Sponsorship.
PART B: Endorsement by Supervisor - Please provide the following information regarding the school where you teach: School Name Street City
State
Zip Code
*Please note that you are required by law to report to IIE any changes to your teaching assignment before any such changes occur. Failure to do so may result in termination of your J-1 Visa Sponsorship. Name of your supervisor at school: ____________________________ Supervisor’s Email: ________________________________________ Telephone: __________________ Temporary teaching exchange opportunity from (EXACT DATES OF THE 2013-2014 SCHOOL YEAR): _____/_____/_____
to: _____/_____/_____
Salary, including any in-kind benefits, if applicable (per-year): US$______________
I hereby certify that the information above concerning the teaching exchange program is true and correct and that our school is extending a temporary teaching exchange opportunity for the period stated above. In compliance with the Code of Federal Regulations, this teaching assignment shall not exceed three years. We also hereby confirm that this teacher’s performance has been satisfactory in all respects and that a new Appointment Letter/Renewal of Contract has been provided to the teacher. Supervisor’s Signature: _______________________________ Date: ____ / ____ / _____ Month
PART C:
Day
Year
Summer 2013 Plans Please briefly explain your plans in the space below (i.e. teaching summer school, taking classes, traveling within the US, going to your home country, etc.):
Should you be traveling outside the U.S. please provide approximate dates of travel: From: _____/_____/_____ to: _____/_____/_____ Contact Information: Address/email/phone number when outside the US:
PART D: Appointment Letter/Renewal of Contract and Passport
Please attach an Appointment Letter/Renewal of Contract Letter from your school/school district that states that you will have a position for the 2012-2013 school year and that your teaching performance has been satisfactory, as well as breaks down your financial support – salary/stipend, in-kind benefits, etc. Please also attach a copy of your passport bio-data page
PART E: Signature “I understand that to qualify for IIE’s continued J-1 sponsorship I cannot accept permanent employment. I hereby certify that all the information above is true and correct and that by accepting continued IIE sponsorship I agree to return to my home country upon the completion of this teaching appointment to fulfill the exchange.” Signature: __________________________________ Date: ____ / ____ / _____
Please be aware that IIE, at its discretion, may terminate your J-1 visa sponsorship for any violation of sponsor rules. Termination of sponsorship may put any future U.S. stay in jeopardy and has serious consequences.
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