Submit by Email Print Form

Program Enrollment Form

Personal Information
Family Name ______First Name Middle Name ______________

 Male  Female Date of Birth: Place of Birth ______

month day year city country

Country of Citizenship/ Residency Passport Number

Address
street address city country postal code

Tel. (home) Tel. (alt) Email

country code/city code/number country code/city code/number

Emergency Contact
relationship full Name

address telephone (country code/city code/number) email

Have you ever applied for a visa to the U.S.?  Yes  No

If yes, in what year? ____________________

Was the visa granted?  Yes  No

Have you ever been to the U.S.?  Yes  No

If YES: Which year: ____ Visa Category: ______________________________

Sponsoring Agency: ________________________ Employer/Position:____________________________________________

Program: _________________________________ Social Security Number: _______________________________________

University Status and Information

Name of University you are presently attending _________________________________________________________________
Address __________________________________________ City ____________________ Country___________________
Field of study ______ _______________ Number of years complete? _______________________
University Entrance Date __ Expected Graduation Date ____ _________
Month Year Month Year

Visa Program Dates The dates below will be printed on your DS-2019 form and reviewed by the US Consul for your Visa!
University Summer Break Dates: Begin: End:
Month Day Year Month Day Year

I, the undersigned applicant, certify that I am a current full time university student in good academic standing and enrolled in a graduate / post
graduate degree program at the accredited academic institute. I intend to visit the USA on the J-1 Work & Travel program during my university
summer break period (Visa Program Dates listed above) and w ill return to my home country to continue my full time studies follow ing my visit to
the USA. I agree to provide the SPONSOR w ith documentation of my full time student status w ith an official university letter signed, stamped, and
dated by my university as verification and proof of my eligibility for this program.

Print Name Signature Date

Employment History and Background
Company Name Your Job Title Your Job Duties and Responsibilities Dates
Start End

Name of Supervisor Company Phone/Email

 Yes  No Do you have any experience Cooking or Food Services?  Yes  No Do you have a National Driver’s License?
 Yes  No Do you have experience using a Cash Register?  Yes  No Do you have experience Housekeeping?
 Yes  No Do you know how to Swim? Please rate your swimming ability (circle one): Beginner / Intermediate / Advanced
 Yes  No Do you have any First Aid or Lifesaving certifications? If YES, please list _____________________________________
Please list any additional Certifications you possess ___________________________________________________________________
 Yes  No Have you ever been convicted of a crime?  Yes  No Will you submit to a background check?
 Yes  No Do you have any visible tattoos?  Yes  No Will you submit to a drug screening test?
 Yes  No Do you have any nose or facial piercing?  Yes  No Will you submit to a health screening test?
 Yes  No Do you have un-naturally colored or styled hair?  Yes  No Will you pay for certification fees for employment?
 Yes  No MALE only. Do you have long hair?  Yes  No MALE only. Do you have a beard or goatee?

 Yes  No Do you agree to follow all employment guidelines and policies set forth by your US employer including, but
not limited to, grooming standards, union dues, drug testing, background checks, fingerprinting, certification fees, uniform cost,
training coursework, transportation and housing cost, and any other mandatory requirements for your employment. ( __ initial here)

1. Number of years you have studied / practiced English? ___________ English Le vel: _______________________

2. Why would you make a good employee for a US company?

3. Why did you choose the Work & Travel Program in the US?

Health Information
Do you have any medical or health conditions that may limit the type of work you can do on this program?  Yes  No
If YES, please explain ___________________________________________________________
Do you have any pre-existing medical conditions (including surgeries, hospitalization, mental illness, or psy chiatric care)?  Yes  No
If YES, please explain
Do you take any medication:  Yes  No If YES, please explain
List any allergies or special dietary restrictions you have:
List any illnesses or physical restrictions you have:
Height inches Weight lbs Do you practice fitness?  Yes  No Do you smoke?  Yes  No
Conv ersion 1m = 37.39inches Conv ersion 1Kg = 2.2Lbs

Can you stand and walk on your legs up to 8 hours?  Yes  No If NO, please explain
Can you physically lift heavy weight up to 20kg repeatedly?  Yes  No If NO, please explain

I hereby certify that I am in good physical and mental health, and I am able to participate in w ork related activities on this program. I have disclosed
all health information and restrictions I am aw are of, and the health information above is true to the best of my know ledge. ( ________ initial here)

Work & Travel Enrollment Agreement

I agree that all the information and documentation provided by me is true to the best of my know ledge. I have not personally misrepresented, and I
do not have know ledge of misrepresentation, on any portion of this application. In the event of misrepresentation, I understand that the SPONSOR
may deny my application and/or dismiss me from the program. I authorize the SPONSOR to distribute the information and photograph provided on
this Enrollment Form to employers and representatives as deemed necessary by the SPONSOR. By signing below , I agree to participate in the
Work & Travel Program and w illingly accept all program terms and conditions set forth by the SPONSOR, and by my designated host US employer.

Print Name Signature Date _____