GENERAL FORMS DESCRIPTION WHO MUST COMPLETE
______________________________ ________________________________________ ______________________________
  • P39 Recharge Form – Visa and Licensing Office
  • P39 Recharge Form – DCISS
  • 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.
    J-1 Exchange Visitors Forms DESCRIPTION WHO MUST COMPLETE
    ______________________________ ________________________________________ ______________________________
  • J-1 Initial Request Checklist
  • J-1 Extension Request Checklist
  • J-1 Amendment Request Checklist
  • J-2 Separate Entry Request Checklist
  • Guide on what needs to be completed and submitted for specific J-1 requests. Department Coordinators
    The department coordinator must submit together with the DS-2019 Request and other supporting documents.
  • Certification of English Proficiency
  • The Department of State requires J-1 Exchange Visitors to have “sufficient proficiency in the English language as determined by an objective measurement of the English language, proficiency to successfully participate in his or her program, and to function on a day- to-day basis.” Department Coordinators
    The certification of English proficiency must be submitted together with the DS-2019 request and other supporting documents.
    This form is required for all “Initial” and “Transfer In” requests
  • J-1 Physicians Scholars
  • The form must be completed if the incoming exchange visitor is a foreign physician participating in UCLA’s J-1 exchange visitor program. Faculty Sponsor
    The department coordinator must submit together with the DS-2019 Request and other supporting documents.
  • J-1 Early Program Completion Form
  • This form is needed when the scholar is ending their program more than 15 days prior to their current DS-2019 end date. Department Coordinators
    The department coordinators must submit the early J-1 program completion form to the VisaAndLicensing@mednet.ucla.edu
  • J-2 Dependent Information Form
  • This form is submitted by the Exchange Visitors to add legal spouse and/or unmarried minor child (under 21 years of age) to the J-1 SEVIS record. Exchage Visitors
    All requests must be returned to the Department Visa Coordinators together with the required supporting documents.
    EXCHANGE VISITOR SUPPLEMENT QUESTIONNAIRES DESCRIPTION WHO MUST COMPLETE
    ______________________________ ________________________________________ ______________________________
  • Exchange Visitor Supplement Questionnaire – Initial Request
  • Exchange Visitor Supplement Questionnaire – Extension Request
  • Exchange Visitor Supplement Questionnaire – Separate Entry J-2 DS-2019 Request
  • The Exchange Visitor Supplement Questionnaires are intended for the exchange visitors to complete to provide the required additional information to their host departments to submit the corresponding DS-2019 requests
    The forms also serve as an attestation of the exchange visitors J-1 regulation eligibility and compliance.
    The request must be submitted to the Visa and Licensing Office together with the all required supporting documents for the J-1 Requests.
    Exchange Visitors
    All requests must be returned to the Department Visa Coordinators together with the required supporting documents.
    ADDRESS AND CONTACT INFORMATION DESCRIPTION WHO MUST COMPLETE
    ______________________________ ________________________________________ ______________________________
  • Address and Contact Information Update Form
  • J-1 Exchange Visitors are required to update the scholars address with the DGSOM Visa and Licensing office within 10 days of changing residence. Exchange Visitors
    The update must be submitted to the VisaAndLicensing@mednet.ucla.edu through the Department Visa Coordinators.
    EMPLOYMENT REQUEST DESCRIPTION WHO MUST COMPLETE
    ______________________________ ________________________________________ ______________________________
  • J-1 Off Campus Activity Request Form
  • This form is needed to request approval from the DGSOM Visa and Licensing Office to engage in off-campus employment.
    This employment is limited to short-term consultations and occasional lectures per U.S. government regulations.
    Exchange Visitor and Host Department
    The request form must be submitted to the DGSOM Visa and Licensing Assistant Director directly.
    If the activity involves remuneration or travel reimbursement, 2 letters will be required from your UCLA faculty supervisor and organization where the activity is taking place.
    TRAVEL AUTHORIZATION DESCRIPTION WHO MUST COMPLETE
    ______________________________ ________________________________________ ______________________________
  • DS-2019 Travel Signature Request Form
  • This form is needed to request official DS-2019 travel validation to re-enter from a trip outside the U.S. Exchange Visitor
    Submit the DS-2019 travel signature request form to: VisaAndLicensing@mednet.ucla.edu
  • J-1 Out of Country Request Form
  • This form is used by J-1 scholars who will continue to pursue their J-1 program objectives while they are outside of the U.S. for more than 30 days but less than one year. Department Coordinators
    The department coordinator must submit the form to: VisaAndLicensing@mednet.ucla.edu
    TRANSFER DESCRIPTION WHO MUST COMPLETE
    ______________________________ ________________________________________ ______________________________
  • Inter-Department Transfer Form
  • Exchange Visitors may be authorized to change departments as long as there are no major changes in the EV’s initial research objectives at UCLA. Department Coordinators
    The department coordinators must submit together with the DS-2019 Request Form and appropriate Recharge Forms.
  • J-1 Exchange Visitor Transfer-In Form
  • This form must be completed if the J-1 scholar intends to transfer their program from another accredited institution within the U.S. to DGSOM. Incoming EV and current ARO/RO
    The form must be submitted together with the DS-2019 Request Forms and other supporting documents.
    MANDATORY CHECK-IN DESCRIPTION WHO MUST COMPLETE
    ______________________________ ________________________________________ ______________________________
  • Exchange Visitor Contract
  • J-1 Visitors Check-in and Arrival Information
  • These forms must be completed by the exchange visitor and submitted to their host department during their mandatory checking-in appointment. Exchange Visitors
    The department coordinators must forward the check-in forms and required documents to the DGSOM Visa and Licensing Office within 25 days of the scholar’s arrival.
    H-1B Temporary Specialty Occupation Worker DESCRIPTION WHO MUST COMPLETE
    ______________________________ ________________________________________ ______________________________
  • 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
    ______________________________ ________________________________________ ______________________________
  • 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
    ______________________________ ________________________________________ ______________________________
  • 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
    ______________________________ ________________________________________ ______________________________
  • 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
    ______________________________ ________________________________________ ______________________________
  • 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
    ______________________________ ______________________________________________________________________
  • Physicians and Surgeons Certification for 2113 Service
  • Letter Template indicating the completion 36 months clinical services, pursuant to Section 2113.
  • 2060 Exemption Request Letter
  •