Fill and Sign the South African Application Form

The Division of International Services 9000 Rockville Pike Building 31, Room B2B07 Bethesda, Maryland 20892-2028 ph (301) 496 6166 Fax (301) 496-0847 http://dis.ors.od.nih.gov/ CHANGE OF ADDRESS NOTICE Federal rules and regulation require all non-immigrants to notify the United States Citizenship and Immigration Services (USCIS), Department of Homeland Security (DHS), of a change of address within (10) days of the move. Use this form to notify the Division of International Services (DIS) immediately upon your change of address. Failure to report the change of address is a violation of immigration status and may lead to termination of the participant's stay in the U.S. and/or other penalties as set by the DHS. You can mail or fax the form to the DIS. Please do not do both. If you fax the form, a fax cover sheet is *not* necessary. ADDITIONAL: • Provide your new address to your Institute/Center's Administrative office (and Office of Human Resources for those in employee/ FTE designations). • NIH-sponsored J-1 and J-2 Exchange Visitors MUST notify DIS of the address change within the ten (10)-day period in order for the DIS to report the change in the Student Exchange Visitor Information System (SEVIS) within the authorized time frame. DIS notification in SEVIS fulfills USCIS's change of address requirements. • This form does NOT replace Form AR-11, which is required by the USCIS for non J-1 Exchange Visitors (or other SEVISreportable visa classifications). Such individuals (e.g. those under an H-1B, O-1, or TN status) must also complete the Form AR-11 to notify USCIS of a change of address. Form AR-11 can be found at http://www.uscis.gov/ under “Forms.” Family Name First Name SEVIS ID number, if any Current immigration status Place of residence* Street Middle Name Date of Birth (MM/DD/YYYY) Country of Citizenship Apt # City State Apt # City State Apt # City State Zip Mailing address, if different than above: Street *Note: A physical street address is required. Zip Previous U.S. address: Street Signature REQUIRED Mail OR Fax form to: Zip Date REQUIRED National Institutes of Health Division of International Services/ORS 31 Center Drive MSC 2028 Building 31 Room B2B07 (301) 496-6166 Fax (301) 496-0847 http://dis.ors.od.nih.gov/ DIS USE ONLY: Approved in NFNIS (date). RO/ARO (initials). Rev. 9/2013