Exchange Visitor: Proof of Student Status

Exchange Visitor Last Name(s):

Exchange Visitor Given Name:

Date of Birth (mm/dd/yyyy):

Email Address:

Home Country Agency Name:

SECTION 1 – UNIVERSITY INFORMATION – must be completed in full

Full Name of University:

University Address:

Official Break Start: Official Break End:

Major field of study: Total years completed:

Professor - Reference Name:

Professor - Reference Email:

SECTION 2 – EXCHANGE VISITOR INFORMATION – must be completed in full
# of previous J exchanges: Program type(s):
Earliest possible program Latest possible
start date: program end date:

Notes on availability:
SECTION 3 – VERIFICATION
To complete your eligibility form please attach the following. Your form is considered incomplete until received.
University Transcript or University course verification page
University Transcript – Certified translation in English

I hereby certify that all of the above information is truthful, accurate, and can be verified with additional
documentation should any be requested. If at any point my university status changes I will notify my home
country agency and United Work and Travel immediately as I recognize my eligibility in this BridgeUSA
program is dependent upon my full time university status.

Exchange Visitor Signature Date

Revised 8/10/2021 (for use in program year 2022)