Cordell Hull Foundation J-1 Teacher ROSTER FORM

This form is for the school staff to fill out.  Teachers:  Do not fill out this form.

NOTE: The Yahoo Interactive Server is currently out of order. Until corrected, please print out your confirmation after clicking on the SUBMIT button at the bottom. Then fax the confirmation to 646-349-3455, a USA digital fax number operational 24 /7. Thank you.

Be sure to spell name exactly as written on the passport. Fill in all blank spaces.

                       Upon completing the form, check all data carefully for accuracy.
                        Then click on the "Submit form"
button on the bottom of the page.

School or District Name

US State where teacher will work

Initial Date of arrival in the US

End date of J-1 visa term
First Name as written in  passport

Middle Name as written in passport

Last Name as written 
in passport

Date of birth



Year of participation in the CHF Exchange Teacher Program

City of Birth

Country of Birth
Country of Citizenship

Country of Legal Residence
Passport Number

Country of Passport Issuance
Home Address in the country of origin
Address in the US (or school/ school district address)

Level that teacher will teach

Name of PERSON completing this form

E-mail address of PERSON completing this form
Annual Salary in US Dollars
Subject to be taught

Number of J-2 family members 

Teacher's Contact Phone in the country of origin
 Teacher's email address
School or District contact person's name and phone no.