1) Visa Applicant Family (Last) Name:
* must provide value
Exactly as it appears in passport
2) Visa Applicant Given (First) Name:
* must provide value
Exactly as it appears in passport
3) Visa Applicant Middle Name(s):
Exactly as it appears on passport
4) Previous Legal Names of the Visa Applicant, if any:
If none, type 'NA'
5) Does the visa applicant presently work at UTSW?
* must provide value
Yes
No
5.a) Provide their UTSW Person ID in the text box provided:
* must provide value
5.b) Provide their current UTSW job title in the text box provided:
* must provide value
5.c) Will they be transitioning into a new role?
* must provide value
Yes
No
5.d) If yes, provide their new UTSW job title they will transition to.
* must provide value
5.c) Provide their anticipated start date at UTSW in the text box provided:
* must provide value
Today M-D-Y
5.d) Provide their anticipated UTSW job title in the text box provided:
* must provide value
5.e) Provide the visa applicant's current city and country of residence:
* must provide value
City/ Country
6) Country of Citizenship:
* must provide value
Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas (the) Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Sint Eustatius, Saba (Netherlands) Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo (Democratic Republic of the) Congo (Republic of the) Cook Islands Costa Rica Cote d'Ivoire Crimea Croatia Cuba Curacao Cyprus Czechia Denmark Djibouti Dominica Dominican Republic Donetsk Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guinea French Polynesia French Southern Territories Gabon Gambia (The) Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran (Islamic Republic of) Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kherson (Ukraine) Kiribati Korea (Democratic People's Republic - North) Korea (Republic of - South) Kosovo Kuwait Kyrgyzstan Laos (Lao People's Democratic Republic) Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luhansk Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands (Kingdom of the) New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestine (State of) Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vicent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part of Saint Martin) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Islands Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania Thailand Timor Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkiye Turkmenistan Turks and Caicos Islands Tuvalu U.S. Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City State Venezuela Vietnam Wallis and Futuna Western Sahara Yamen Zambia Zaporizhzhia (Ukraine) Zimbabwe
Country of citizenship may differ from the city and country of their current residence.
6.a) If the visa applicant holds citizenship with more than one country, please select the additional country from the drop-down list.
Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas (the) Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Sint Eustatius, Saba (Netherlands) Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo (Democratic Republic of the) Congo (Republic of the) Cook Islands Costa Rica Cote d'Ivoire Crimea Croatia Cuba Curacao Cyprus Czechia Denmark Djibouti Dominica Dominican Republic Donetsk Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guinea French Polynesia French Southern Territories Gabon Gambia (The) Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran (Islamic Republic of) Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kherson (Ukraine) Kiribati Korea (Democratic People's Republic - North) Korea (Republic of - South) Kosovo Kuwait Kyrgyzstan Laos (Lao People's Democratic Republic) Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luhansk Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands (Kingdom of the) New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestine (State of) Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vicent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part of Saint Martin) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Islands Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania Thailand Timor Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkiye Turkmenistan Turks and Caicos Islands Tuvalu U.S. Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City State Venezuela Vietnam Wallis and Futuna Western Sahara Yamen Zambia Zaporizhzhia (Ukraine) Zimbabwe
7) Date of Birth:
* must provide value
M-D-Y
8) Attach a copy of the visa applicant's curriculum vitae (CV) or Biosketch.
* must provide value
9) Indicate visa type:
* must provide value
H-1B J-1 F-1 O TN Other Unknown
9.a) If "Other," please indicate the current visa type in the text box provided:
* must provide value
9.b) Will the visa type change once the visa applicant joins UTSW?
Yes
No
Unsure
9.c) Will the visa applicant be transitioning to a different visa type?
Yes
No
Unsure
9.d) Describe the circumstances with which the visa type may change. If unknown, type 'Unknown'.
If unknown, type 'Unknown'.
9.f) If applicable, please upload a copy of the accompanying Letter of Support or Training/Internship Placement Plan (DS-7002).
10) Name of Principal Investigator/Supervisor at UTSW:
* must provide value
11) Primary UTSW Department:
* must provide value
Advanced Imaging Research Center Anesthesiology & Pain Management Animal Resource Center Biochemistry Bioinformatics Biomedical Engineering Biophysics Cardiovascular & Thoracic Surgery Cell Biology Center for Alzheimer's & Neurodegenerative Disease Center for Genetics of Host Defense Center for Human Nutrition Children's Research Institute Clinical Informatics Centers Dermatology Emergency Medicine Family Medicine Green Center for Reproductive Biology Hamon Center for Regenerative Science and Medicine Hamon Center for Therapeutic Oncology Research Health System Affairs Immunology Information Resources Internal Medicine - All Divisions McDermott Center Microbiology Mineral Metabolism and Clinical Research Molecular Biology Molecular Genetics Neurological Surgery Neurology Neuroscience Obstetrics & Gynecology Ophthalmology Orthopedic Surgery Otorhinolaryngology - All Divisions Pathology Pediatrics - All Divisions Peter O'Donnell Jr. Brain Institue (including School of Public Health and Population & Data Sciences) Pharmacology Physical Medicine & Rehabilitation Physical Therapy Physiology Plastic Surgery Psychiatry Radiation Oncology Radiology Research Support and Regulatory Management School of Health Professions Scottish Rite Hospital Simmons Comprehensive Cancer Center Sponsored Project Administration (SPA) Surgery - All Divisions Touchstone Center for Diabetes Research University Hospitals Urology Other
11.a) If "Other" is selected, please list department:
* must provide value
12) UTSW Building, Floor, and Room Location:
* must provide value
List the primary work site for the visa applicant. In unknown, type 'Unknown'
1) Select 'Yes' to provide information on any current and/or past (within 5 years) non-US affiliations.
* must provide value
Yes
No
1.a) Name of entity:
* must provide value
1.b) City/ Country of entity:
* must provide value
1.c) Name of immediate supervisor and/or mentor at the entity:
* must provide value
If unknown, type 'NA'
1.d) Will this relationship/affiliation continue after the visa applicant joins UTSW?
* must provide value
Yes
No
1.e) Provide the date of last attendance/affiliation with this entity:
* must provide value
Today M-D-Y
1.f) Describe the nature of the relationship/affiliation in the text box provided:
* must provide value
2) Select 'Yes' to provide an additional entity.
* must provide value
Yes
No
2.a) Name of entity:
* must provide value
2.b) City/ Country of the entity:
* must provide value
2.c) Name of immediate supervisor and/or mentor at the entity:
* must provide value
If unknown, type 'NA'
2.d) Will this relationship/affiliation continue after the visa applicant joins UTSW?
* must provide value
Yes
No
2.e) Provide the date of last attendance/affiliation with this entity:
* must provide value
Today M-D-Y
2.f) Describe the nature of the relationship/affiliation in the text box provided:
* must provide value
3) Select 'Yes' to provide an additional entity.
* must provide value
Yes
No
3.a) Name of entity:
* must provide value
3.b) City/Country of entity:
* must provide value
3.c) Name of immediate supervisor and/or mentor at the entity:
* must provide value
If unknown, type 'NA'
3.d) Will this relationship/affiliation continue after the visa applicant joins UTSW?
* must provide value
Yes
No
3.e) Provide the date of last attendance/affiliation with this entity:
* must provide value
Today M-D-Y
3.f) Describe the nature of the relationship/affiliation in the text box provided:
* must provide value
4) Select 'Yes' to provide an additional entity.
* must provide value
Yes
No
4.a) Name of entity:
* must provide value
4.b) City/Country of entity:
* must provide value
4.c) Name of immediate supervisor and/or mentor at the entity:
* must provide value
4.d) Will this relationship/affiliation continue after the visa applicant joins UTSW?
* must provide value
Yes
No
4.e) Provide the date of last attendance/affiliation with this entity:
* must provide value
Today M-D-Y
4.f) Describe the nature of the relationship/affiliation in the text box provided:
* must provide value
5) Select 'Yes' to provide an additional entity.
* must provide value
Yes
No
5.a) Name of entity:
* must provide value
5.b) City/Country of entity:
* must provide value
5.c) Name of immediate supervisor and/or mentor at the institution:
* must provide value
5.d) Will this relationship/affiliation continue after the visa applicant joins UTSW?
* must provide value
Yes
No
5.e) Provide the date of last attendance/affiliation with this institution:
* must provide value
Today M-D-Y
5.f) Describe the nature of the relationship/affiliation in the text box provided:
* must provide value
6) If there are additional non-US affiliations to provide, they may be described in the text box here:
7) Does the visa applicant have any current or past military affiliations?
Military affiliations include voluntary as well as government mandated, conscripted, or compulsory service and/or training, regardless of duration. Inaccurate or incomplete responses may result in delays in approval and/or local, state, and federal penalties.
* must provide value
Yes
No
7.a) Describe the nature of the military affiliation in the text box provided:
* must provide value
(Country, role, field)
1) Will salary or other financial support be received from any non-UTSW source during the visa applicant's time at UTSW?
* must provide value
Yes
No
1.a) List the name of the entity providing support:
* must provide value
1.b) To whom will the funds be paid?
* must provide value
(e.g. UTSW, directly to the individual, etc.)
1.c) Upload letters of financial support here:
* must provide value
2) Select 'Yes' to provide additional salary or other financial support the visa applicant will receive from a non-UTSW source.
* must provide value
Yes
No
2.a) List the name of the entity providing support:
* must provide value
2.b) To whom will the funds be paid?
* must provide value
(e.g. UTSW, directly to the individual, etc.)
2.c) Upload letters of financial support here:
* must provide value
3) Select 'Yes' to provide additional salary or other financial support the visa applicant will receive from a non-UTSW source.
* must provide value
Yes
No
3.a) List the name of the entity providing support:
* must provide value
3.b) To whom will the funds be paid?
* must provide value
(e.g. UTSW, directly to the individual, etc.)
3.c) Upload letters of financial support here:
* must provide value
4) If there are additional non-UTSW sources of financial support to provide, they may be described in the text box here:
1) Will the visa applicant be involved in research at UTSW?
* must provide value
Yes
No
1.a) Describe the work responsibilities that will be assigned and include specific references to the aims/goals of the research project(s).
* must provide value
1.b) Upload any additional reference material if needed.
1.c) Provide a brief description of the visa applicant's work responsibilities.
* must provide value
Select an appropriate response below and proceed to the follow-up questions:
2) Will the project or work responsibilities include nuclear materials and/or related facilities and equipment?
* must provide value
Yes
No
2.a) Provide a brief description of the nuclear materials, facilities, and/or equipment:
* must provide value
Yes
No
3.a) Provide a list of the biological materials, chemicals, micro-organisms, disease causing agents (pathogens), and/or select agents and/or toxins:
* must provide value
4) Will the project or work responsibilities include the design, development, and production of highly specialized electronics/computers, related equipment, and/or network software including telecommunications and/or information security equipment?
* must provide value
Yes
No
4.a) Provide a description of the equipment and/or software.
* must provide value
4.b) Will the visa applicant have access to source code?
* must provide value
Yes
No
4.c) If yes, will data, encrypted or otherwise, be sent to or from, or be stored in a country other than the U.S.?
* must provide value
Yes
No
4.d) If yes, select the country.
* must provide value
Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antartica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas (the) Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Sint Eustatius, Saba (Netherlands) Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo (Democratic Republic of the) Congo (Republic of the) Cook Islands Costa Rica Cote d'Ivoire Crimea Croatia Cuba Curacao Cyprus Czechia Denmark Djibouti Dominica Dominican Republic Donetsk Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guinea French Polynesia French Southern Territories Gabon Gambia (The) Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran (Islamic Republic of) Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kherson (Ukraine) Kiribati Korea (Democratic People's Republic - North) Korea (Republic of - South) Kosovo Kuwait Kyrgyzstan Laos (Lao People's Democratic Republic) Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luhansk Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands (Kingdom of the) New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestine (State of) Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vicent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part of Saint Martin) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Islands Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania Thailand Timor Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkiye Turkmenistan Turks and Caicos Islands Tuvalu U.S. Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City State Venezuela Vietnam Wallis and Futuna Western Sahara Yamen Zambia Zaporizhzhia (Ukraine) Zimbabwe
5) Will the project or work responsibilities include customized laser and sensor equipment and/or software not ordinarily commercially available?
* must provide value
Yes
No
5.a) Describe the laser and sensor equipment and/or software.
* must provide value
6) Does the project or work responsibilities include UTSW-owned Technical Data/Intellectual Property (IP).
* must provide value
Yes
No
6.a) Describe the UTSW-owned Technical Data/IP in the text box provided.
* must provide value
1) Will the work/research project(s) receive any local, state, or federal/U.S. government funding?
* must provide value
Yes
No
1.a) If Yes, list the agencies in the text box provided:
* must provide value
3) Does the research statement of work or any language in the research agreement reference U.S export regulations or security restrictions, beyond a mere statement that UTSW will comply with applicable export control laws and regulations?
* must provide value
Yes
No
3.a) Please attach a copy of the research statement of work or research agreement which includes this information.
* must provide value
4) Does the research statement of work or any language in the research agreement prohibit the involvement of non-U.S. persons or persons from certain countries, or require sponsor approval for the participation of non-US persons or persons from certain countries?
* must provide value
Yes
No
4.a) Please attach a copy of the research statement of work or research agreement which includes this information.
* must provide value
5) Does the research statement of work or any language in the research agreement require UTSW to identify foreign nationals and/or their citizenship?
* must provide value
Yes
No
5.a) Please attach a copy of the research statement of work or research agreement which includes this information.
* must provide value
6) Does the research statement of work or any language in the research agreement prohibit access to projects materials/data/information for non-U.S. persons?
* must provide value
Yes
No
6.a) Please attach a copy of the research statement of work or research agreement which includes this information.
* must provide value
Please include any additional information, not otherwise addressed, that you would like the Export Control Office to know about in the text box provided:
Contact name:
* must provide value
Contact email:
* must provide value
Thank you for completing the Export Control Questionnaire. If additional information is required or the information available requires additional review, the Export Control Office will notify the submitter. Export Control - Research Administration and review policy ETH-401 Export Controls.
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