ࡱ> 574 bjbj 0eeq n8000FFF!!!%'''''',S!!!!!SFFh!RFF%!%)$Жsj~0::4!!!SS!!!:!!!!!!!!! :   VSA Questions This form may be used if the department will not sponsor a J-1 visa for the Visitor. Submit the completed Questionnaire with the signed Visiting Scientist/Scholar Agreement to the Office of Research and Development (jsimons@umaryland.edu) for review and signature on behalf of UMB. Full Name of Visiting Scientist/Scholar ___________________________________________________________ Will the Visiting Scientist/Scholar represent a company or institution? ___Yes ___No If yes, name of organization:________________________________________________________________ Will the Visiting Scientist/Scholar receive compensation or salary from UM during their visit? ___Yes ___No If no, Visiting Scientist/Scholars visit is funded by: ____________________________________ What is the purpose of the visit? _________________________________________________________________ ________________________________________________________________________________________________________ Describe the visitors planned research, education and/or training activities at UMB. A project description may be attached to the agreement. If visitors planned activities are related to a UMB sponsored project, provide award information (sponsor and Project ID and/or agency grant number). ________________________________________ ________________________________________________________________________________________________________ State specifically where the Visiting Scientist/Scholar will be working at UMB (buildings/rooms): ________________________________________________________________________________________________________ Will the Visiting Scientist/Scholar have access to other faculty members and their laboratories or to other UMB facilities or to resources not otherwise open to the public? ___Yes ___No If yes, describe: _____________________________________________________________________________ ________________________________________________________________________________________________________ Will the Visiting Scientist/Scholar have access to existing or potential UMB intellectual property? ___Yes ___No Will the Visiting Scientist/Scholar bring any research material with him/her? ___Yes ___No If yes, will the Visiting Scientists/Scholars research material be co-mingled with any other material developed either by the Faculty Sponsor named on the VSA or by another faculty member at UM? ___Yes ___No Visiting Scientist/Scholar is a: _____US Citizen _____US Permanent Resident _____Foreign national [A foreign national, for this purpose, is a person who is NOT a U.S. citizen, a U.S. permanent resident or a protected person (refugee, asylum holder).] Country of citizenship ______________________________________________ Visa type (e.g. J-1, F-1) _____________________________________________ Attach a copy of the completed J-1 Visa Request Form if available, CV, letter of invitation, and/or other information regarding the Visiting Scientist/Scholar. SUBMITTED BY: ___________________________________________________________ DATE________________ Email: ______________________________________________________________________     Rev. 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