Forms | UCLA Medical School

GENERAL FORMS	DESCRIPTION	WHO MUST COMPLETE
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P39 Recharge Form – Visa and Licensing Office	Recharge Forms (formerly P39)	All departments requesting services from the DGSOM Visa and Licensing Office.
DGSOM Visa and Licensing Fee Structure	Summary of the Recharge Fee for Visa and Licensing Office	Department Coordinators These are the most current fees for Visa and Licensing Services.

H-1B Temporary Specialty Occupation Worker	DESCRIPTION	WHO MUST COMPLETE
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Request for H-1B Sponsorship	For initial, extension, and amendment requests for Specialty Occupation Workers that are submitted to DCISS.	Department Coordinators The department coordinators must initiate an H-1B Action in VITS for records and reports keeping and must send this form to Joan Cerera.

O-1 Extraordinary Ability	DESCRIPTION	WHO MUST COMPLETE
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O-1 Request for Eligibility Review	For initial O-1 Application. This form is used to request DGSOM Visa and Licensing Office and the Outside Counsel to review a prospective or current UCLA employee’s eligibility for O-1 Extraordinary Ability.	Department Coordinators Please complete and email to JCerera@mednet.ucla.edu together with a copy of the Foreign National’s most recent CV. Do not include recharge form (P39).
O-1 Department Sponsorship Request Form	This form is used to request for the DGSOM Visa and Licensing Office to file an O-1 petition for a prospective or current employee at UCLA.	Department Coordinators Once the O-1 eligibility determination has been conferred by the Visa Office Assistant Director, the department coordinators must initiate an O-1 Action in VITS for records and reports keeping and must send this form to Joan Cerera together with the required documents and the Visa Office Recharge Form.
Letter of Request for O-1 Sponsorship	Letter Template from the Department Chair justifying the need to fill the position and how the Foreign National will benefit UCLA.	Department Coordinator signed by the Department Chair This letter must be submitted together with the O-1 Department Sponsorship Request Form

Permanent Residence	DESCRIPTION	WHO MUST COMPLETE
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PR Request for Eligibility Review	For PR Sponsorship. This form is used to request DGSOM Visa and Licensing Office and the Outside Counsel to review a prospective or current UCLA employee’s eligibility for PR sponsorship.	Department Coordinators Please complete and email to JCerera@mednet.ucla.edu together with a copy of the Foreign National’s most recent CV. Do not include recharge form (P39).
PR Department Sponsorship Request Form	This form is used to request for the DGSOM Visa and Licensing Office to file a PR Sponsorship for a prospective or current employee at UCLA.	Department Coordinators Once the PR eligibility determination has been conferred by the Visa Office Assistant Director, the department coordinators must initiate a PR Action in VITS for records and reports keeping and must send this form to Joan Cerera together with the required documents and the Visa Office Recharge Form.
Letter of Request for PR Sponsorship	Letter Template from the Department Chair justifying the need to fill the position and how the Foreign National will benefit UCLA.	Department Coordinator signed by the Department Chair This letter must be submitted together with the PR Department Sponsorship Request Form.

2111	DESCRIPTION	WHO MUST COMPLETE
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2111 and 2113 Initial Application Request	This form is used to request 2111 or 2113 Special Programs License for Foreign M.D.	Department Coordinators The department coordinators must initiate a 2111/2113 Action in VITS for records and reports keeping and must send this form to Joan Cerera together with the MBC Forms and other required documents plus Visa Office Recharge Form.
2111 and 2113 Renewal Application Request	This form is used to request the renewal of 2111 or 2113 Special Programs License for a Foreign M.D.	Department Coordinators This letter must be submitted together with the 2111/2113 Renewal Application.
2111 Department Letter to Request Dean’s Office Support	Letter Template from the Department Chair requesting the DGSOM Dean’s Office support of the Appointment pursuant to Section 2111.	Department Coordinator signed by the Department Chair This letter must be submitted directly to Joan Cerera together with the following: Initial/Extension Application Request MBC 2111/2113 Application Required Documents Recharge Fee (P39) for the Vice Dean of Faculty approval and signature

2113	DESCRIPTION	WHO MUST COMPLETE
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2111 and 2113 Initial Application Request	This form is used to request 2111 or 2113 Special Programs License for Foreign M.D.	Department Coordinators The department coordinators must initiate a 2111/2113 Action in VITS for records and reports keeping and must send this form to Joan Cerera together with the MBC Forms and other required documents plus Visa Office Recharge Form.
2111 and 2113 Renewal Application Request	This form is used to request the renewal of 2111 or 2113 Special Programs License for a Foreign M.D.	Department Coordinator signed by the Department Chair This letter must be submitted together with the 2111/2113 Renewal Application.
2113 Department Letter to Request Dean’s Office Support	Letter Template from the Department Chair requesting the DGSOM Dean’s Office support of the Appointment pursuant to Section 2113.	Department Coordinator signed by the Department Chair This letter must be submitted directly to Joan Cerera together with the following: Initial/Extension Application Request MBC 2111/2113 Application Required Documents Recharge Fee (P39) for the Vice Dean of Faculty approval and signature

MBC Letters	DESCRIPTION
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Physicians and Surgeons Certification for 2113 Service	Letter Template indicating the completion 36 months clinical services, pursuant to Section 2113.
2060 Exemption Request Letter