J-1 Student Intern Form

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Please submit this form if you have been accepted to complete an internship at Cal Poly for credit at your home institution and you need a J-1 visa to enter the USA.  If you have questions, please contact Susan Tripp.

You must also complete the DS-2019 Request Form.

You will not be able to save this form and complete it later. Be prepared to upload a copy of your approved internship agreement.

Please provide your Family (Surname/Last) name as it appears on your passport.
Please provide the name of the department office where you will be working at Cal Poly for your internship.
Upload the approved internship agreement between Cal Poly and your home institution
Files must be less than 2 MB.
Allowed file types: gif jpg png pdf doc docx rar.

By typing my name below, I affirm that all the information I have provided is accurate. I understand that this information will be used to evaluate my eligibility for DS-2019 issuance in the Student Intern Category. I will immediately inform California Polytechnic State University (Cal Poly) of any changes in the information I have provided. I understand that the duration of my internship cannot be extended without the permission of Cal Poly and must be done prior to the expiration of the DS-2019. I also understand that as an exchange visitor I am not eligible to earn a degree at Cal Poly.

I type my name as if signing on paper.

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