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Foreign National Information Form

Last (Family) Name

First

Date of Birth

Middle
NC State (Student/Staff) ID #

Social Security Number

What department are you working for?

What is your job title?

E mail Address:

Job start date

What was the arrival date of your FIRST visit to the US? (If you have been in the US for
any reason, including tourism, prior to your arrival at NC State please complete
section 1 on page 2 of this form.)
Address in United States

Foreign Resident Address

Street Address 1

Street Address 1

Street Address 2

Street Address 2

City

City

State

Zip Code

Province/Region

Postal Code

Country of citizenship

Country

Foreign Taxpayer ID
Passport expiration date

Passport #
Are you a citizen of any country other than your country of birth?
(i.e. Do you have a passport from another country or are your
parents citizens of another country? )

If yes, what country?

Visa Type

If J-1, what is the subtype?

Yes

What is the primary activity of THIS visit?

If you are a student, what type?

Visa control number

Visa issue date

What is the start date


of your I-20 or DS2019?
Are you married?

No

Yes

Visa expire date

What is the end date


of your I-20 or DS2019?

No

If yes, is spouse in US with you?

Have you ever lived in any country other than


your home country before coming to the US?

Yes

No

Yes (Please complete section 2 on page 2 of this form)

No

I hereby certify that all of the above information is true and correct. I understand that if any of the information changes I must contact the
International tax office immediately.
Signature
Date
Please send a PDF version of your completed form to: foreignnationaltax@ncsu.edu prior to your tax assessment.

Foreign National Information Form


Page 2
Section1 - If you have been in the US prior to your arrival at NC State you must provide the following information. "Date of Entry" is your
first day in the US on that visa. "Date of Exit" is the last day in the US on that Visa. Use date format MM/DD/YYYY
Date of Entry

Visa Type
Immigration Status

Date of Exit

Subtype
(If on a J-1 Visa)

Primary Activity
of Visa

Did you use


treaty benefits?
Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Section 2 - If you have lived in another country in the last five years, prior to coming to the US, your country of tax residence may be
different from your foreign residency address.
Have you lived (worked/attended school) in another country other than the US or your home country in the last five years?
Yes

No

Name of Country
Start Date

End Date

I consent to allow International Employment & Taxation (IET) to access my electronic I-94 record and/or travel history using the U.S.
Customs and Border Protection's online I-94 retrieval system at www.cbp.gov/i94. Initial: