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Program of Interest

J-1 Summer Work and Travel program
J-1 USA Internship/ Trainee

Name *

First

Middle

Last

Gender

Male
Female

Passport Number

Passport Issue Date

Passport Expiration Date

Date of Birth

Parish of Birth

Email *

Home Phone

Cell Phone *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Have you ever been denied a visa? *

Date of visa denial

If yes, please state the type of visa and reason for denial.

Have you ever participated on any of the programs below? If yes, select the program. *

How many times have you ever participated on the J1 or the H2B program?

Have you ever entered the United States? If yes, please provide the exact date.

Are you currently on U.S immigration filing? If yes, kindly provide the case number.

Have you ever been arrested?

If yes, state reason

Have you ever been convicted of a crime?

Do you have any serious illnesses and/or allergies?

P.S: If you are currently pregnant or is expected to be while on the program, please refrain from registering. Unfortunately, the insurance provided by the agency/sponsor does not cover pre-existing health conditions. If found in violation, you will be asked to end program early.

Do you require special placement? If yes, please provide the name of individuals you would like to be placed with.

What is your preferred location?

What is your preferred position?

Referred By

How did you hear about us?

Name *

First

Middle

Last

Relationship to Applicant

Home Phone

Cell Phone *

Email *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Name of Institution

Program of Study

Start Date

When did you enrolled in program?

Finish Date

When will you finish your studies?

Phone

School contact number

School Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Company Name

Job Title

Duties

Start Date

Finish Date

Phone

Company Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Company Address (copy)

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Company Address (copy) (copy)

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

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May’ Fos Work & Travel Agency

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