8/7/2019 Work and Travel Application

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Program Enrollment Form

Personal Information Family Name ______First Name Middle Name ______________

Male Female Date of Birth: Place of Birth

month day year cityCountry of Citizenship/ Residency Passport Number

Address

street address city country postal codeTel. (home) Tel. (alt) Email

country code/city code/number country code/city code/numberEmergency Contact

relationship full Nam

address telephone (country code/city

University Status and InformationName 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

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

Month Day Year Month D

I, the undersigned applicant, certify that I am a current full time university student in good academic standing and enrolled in a graduate / postgraduate degree program at the accredited academic institute. I intend to visit the USA on the J-1 Work & Travel program during my universitysummer break period (Visa Program Dates li sted above) and w ill return to my home country to continue my f ull time studies follow ing my visit tothe USA. I agree to provide the SPONSOR w ith documentation of my f ull time student status w ith an off icial university letter signed, stamped, anddated by my univers ity as verif ication and proof of my eligibility for this program.

Print Name Signature Date

Have you ever applied for a visa to the U.S.? Yes NoIf yes, in what year? ____________________Was the visa granted? Yes NoHave you ever been to the U.S.? Yes No

If YES: Which year: ____ Visa Category: ______________________________

Sponsoring Agency: ________________________Employer/Position:____________________________________________ Program: _________________________________Social Security Number: _______________________________________

Print FormSubmit by Email

8/7/2019 Work and Travel Application

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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 Drivers 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): Beginne r / Intermediate / AdvancedYes 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 subm it to a drug screening test? Yes No Do you have any nos e or facial piercing? Yes No Will you submit to a heal th screening test? Yes No Do you have un-naturally colored or s tyled 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, butnot 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 Level: _______________________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 NoIf YES, please explain ___________________________________________________________

Do you have any pre-existing medical conditions(including surgeries, hospitalization, mental illness, or psy chiatric care)? Yes NoIf 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 NoConv 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 cer tify that I am in good physical and mental health, and I am able to partic ipate in w ork related activities on this program. I have disclosedall health information and restrictions I am aware of, and the health information above is true to the best of my know ledge. ( ________ init ial 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 Ido not have knowledge of misrepresentation, on any portion of this application. In the event of misrepresentation, I understand that the SPONSORmay deny my application and/or dismiss me from the program. I authorize the SPONSOR to distribute the information and photograph provided onthis 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