Research Corporation of the University of Hawaiʻi

Research Corporation
of the University of Hawai‘i
Human Resources Department
J-1 PROGRAM COMPLETION FORM
The J-1 exchange visitor must complete and submit this form when he/she is ending his/her J-1 program with the Research Corporation of the University of Hawaii (RCUH). Send the completed form to the program’s Principal Investigator/Administrator along with copies of the return air ticket(s) or itinerary for the J-1 and each J-2 dependent. This verification is required to ensure RCUH’s compliance with federal government regulations.
Employee’s Name (J-1): _____________________________________________________________________________
Program: _________________________________________________________________________________________
DS-2019 end date (mm/dd/yyyy): _______________ Last day of program activity in the U.S. (mm/dd/yyyy): ___________
U.S. departure date (mm/dd/yyyy): ______________ Departure port (city): ____________________________________
J-1 Program Completion Form MUST be submitted to RCUH Human Resources at least two (2) weeks before the last day of the program.
Reason for departing the U.S.:
Completion of J-1 program based on DS-2019 end date or less than 30 days before DS-2019 end date Early completion of J-1 program (i.e., 30 days or more before DS-2019 end date)
Inability to continue J-1 program
Withdrawal from the J-1 program
Terminated from the J-1 program
If you are not departing the U.S., please explain why:
Change of status to new visa (e.g., F-1, H-1B) , sponsored by Other reason:
UH RCUH
Other
Forwarding address: _____________________________________________________________________________
Telephone: _____________________________ Email: _______________________________________________
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Certification:
Employee’s Signature: (J-1 Exchange Visitor): ____________________________________ Date: ________________ Principal Investigator/Designee (Print Name): ____________________________________________________________ Principal Investigator/Designee (Signature): _______________________________________ Date: _________________ RCUH Human Resources Confirmation: _____________________________________________ Date: __________________
ATTACH COPIES OF DEPARTURE AIR TICKET(S) OR AIRLINE-ISSUED ITINERARY FOR THE J-1 AND EACH J-2 DEPENDENT
RCUH Form I-109
Created 09/14 (Revised 04/16)