Declaration of Family Members and Relatives in the United States of America Pursuant to Section II, Item 10 of the Program Terms and Conditions of 2015 USA Work and Travel (WAT 2015- Form 3) that my parents/guardians and I have signed, I, [Name of Participant] declare that I have the following family members/relatives in the United States of America: Name: Relationship: Status in US:

Home Address: Home Phone:

Company: Position: Office Number:

Name: Relationship: Status in US:

Home Address: Home Phone:

Company: Position: Office Number:

Name: Relationship: Status in US:

Home Address: Home Phone:

Company: Position: Office Number:

Name: Relationship: Status in US:

Home Address: Home Phone:

Company: Position: Office Number:

Name: Relationship: Status in US:

Home Address: Home Phone:

Company: Position: Office Number:

(Attach separate sheet if you require additional space) I understand that failure to disclose truthfully the required information may result to cancellation of my application or termination of my program. _______________________________ __________________ WAT 2015 Applicant/ Date Visa Sponsor ________________________________ Parents/Guardian of Applicant/ Date