Request for Visiting Scholar Agreement (VSA)

Name of College of Medicine Faculty Member serving as Individual Host for Visiting Scholar

Name of College of Medicine Faculty Member serving as Administrative Host

Examples would include the College Dean, Research Dean, Department Head, Chancellor, or Institute Director. Cannot be the same as Individual Host.

Department

Specify Department

Name of Penn State Employee Submitting Request

Email of Penn State Employee Submitting Request

Legal name of Visiting Scholar
must match visa documentation

Degree of Visiting Scholar

MDPhDMD/PhDOther

Specific Degree Status

Address of Visiting Scholar

Email of Visiting Scholar

Phone Number of Visiting Scholar

Name of Visiting Scholar's Home Institution

Beginning Date of Visit

Start date must fall on a NEO date – please consult the New Employee Orientation Dates list from HR for acceptable dates

End Date of Visit

Objectives of the Visit

Will the Visiting Scholar be fully paid by the home institution?

YesNo

Please explain.

Will any internal funding be used to supplement this visit?

YesNo

Describe the internal funding to be used.

Please attach an abbreviated CV - 2 pages maximum

PDF format only

Please attach the financial support letter

PDF format only

Please attach any other supporting documentation

PDF format only