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Rutgers Biomedical and Health Sciences International Services
65 Bergen Street, Room GA 72, Newark, NJ 07101-1709 * Phone: 973-972-6138 Fax: 973-972-8260
CHECK-IN FORM
Campus location:
Camden
New Brunswick
Immigration status:
F-1
Newark
H-1
Piscataway
J-1
O-1
Scotch Plains
Gender:
M
Stratford
Marital Status:
F
Single
Married
Date of birth
Divorced
Family Name
First Name
Middle Name
RBHS ID#
Personal email address:
RBHS email address:
Local Address
Street name and number:
Apt. number
City
State
Home/Cell Phone Number
Zip Code
Work Phone Number
Permanent Address Abroad (please enter complete address)
Address:
Country
Phone # Abroad
City of Birth
Country of birth
Country of Citizenship
Country of legal Permanent Residence
I-94 Card #
Date of last entry into the U.S.
For Students only:
School:
Port of entry
For Faculty/Staff only:
Job Title:
GSBS
NJDS
SHRP
SN
SOM
SPH
Supervisor:
Dept. Administrator
Department/Program:
Location of Employment:
Degree sought:
Street Address
Expected Completion Date:
City/State/Zip
Telephone #
Revised: 6/2013
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Complete this section for dependents
INSTRUCTIONS: Please include copies of your dependent's passport, visa, I-94 card and DS-2019.
Dependent #1
Relationship:
Spouse
Child
Family name
Visa Status:
F-2
J-2
First name
H-4
Other
Middle name
Dependent #2
Relationship:
Spouse
Child
Family name
Visa Status:
F-2
J-2
First name
H-4
Other
Middle name
Dependent #3
Relationship:
Spouse
Child
Family name
Visa Status:
F-2
J-2
First name
H-4
Other
Middle name
Dependent #4
Relationship:
Family name
Revised: 6/2013
Spouse
Child
Visa Status:
First name
F-2
J-2
H-4
Other
Middle name
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