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app.2012[1]

app.2012[1]

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Published by: sasastojmenovic1325 on Feb 21, 2012
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02/21/2012

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www.ciee.org/watWork & Travel USA
Last updated 2011.08.01
Work & Travel USA
Application Spring/Summer 2012
Name o CIEE Representative: Country:Interviewed by (name): Representative Code:Date (day/month/year):
PLEASE FILL IN FORM USING ALL CAPITAL LETTERS.
Departure and Return Dates
Arrival date in U.S.
(DD/MM/YYYY)
:
Can be no more than ve days prior to DS-2019 start date.
DS-2019 start date
(DD/MM/YYYY)
:
Date you want to be eligible to work in the U.S.
DS-2019 end date
(DD/MM/YYYY)
:
Last day you want to be eligible to work in the U.S. Can be no more than our months ater DS-2019 start date.
Date o departure rom U.S.
(DD/MM/YYYY)
:
Can be no more than 30 days ater DS-2019 end date and no more than ve months ater arrival date.
Personal Details
Exactly as they appear on your passport. Please include a copy o your passport’s ID page with your application.
Last Name:Middle Name:First Name:Gender:
Female
Male Date o Birth
(DD/MM/YYYY)
:City o Birth: Country o Birth:Country o Citizenship:Country o Legal Residence:Passport Number:Passport Expiration Date
(DD/MM/YYYY)
:
Contact Inormation
Permanent Home Address
Home Mailing Address:Postal Code: City: Country:Phone Number
(Country code - City code - Number)
: Mobile Number:Email
(Mandatory)
:
Emergency Contact
Last Name: First Name:Relationship to Participant:Address:Postal Code: City: Country:Phone Number
(Country code - City code - Number)
: Mobile Number:Email:
Previous Visas
I you have previously received more than one J-1 Visa, please use an additional sheet o paper to provide the same inormation as below or each one.
Have you ever received a J-1 visa to enter the USA?:
Yes
No I yes, how many?:I yes, please complete the ollowing or each previous J-1 visa:Name o Program: Program Number:Name o Sponsoring Organization: City: State:Dates o Previous DS-2019 Form: From
(DD/MM/YYYY)
: To
(DD/MM/YYYY)
:
Other Visa Inormation
Have you ever applied or a visa to emigrate permanently to the U.S.?
Yes*
NoHave you ever been arrested and convicted o a crime?
Yes*
NoHave you ever been reused a visa by a U.S. Embassy?
Yes*
No*I you answered Yes to any o these questions, please contact your CIEE Representative.
 
www.ciee.org/watWork & Travel USA
Last updated 2011.08.01
Work & Travel USA
Application Spring/Summer 2012
Name o CIEE Representative: Country:Interviewed by (name): Representative Code:Date (day/month/year):
University/College
Name o Institution
(e.g. university, polytechnic)
:City:Major Field o Study:What is the course length o your major feld o study (in years)?:How many years o university-level study will you have completed by the time o your departure to the U.S.?:Will you be a ull-time university-level student at the time you leave to the U.S.?:Will you be a ull-time university-level student when you return to your country o residence?:
Proo o Student Status
 
This section must be completed by an ofcial rom your educational institution.I your educational institution will not sign this orm you must attach an ofcial letter on university letterhead veriying this same inormation.
I certiy that the named student is registered in our institution as a ull-time student or the academic year 2012 and is returning toull-time studies in the semester ollowing the program.
Name o Student:Name o the Ofcial signing the Form: Title:Signature:School Seal/Stamp: Date
(DD/MM/YYYY)
:
English Language Ability
This section must be completed by an English teacher.
Oral English Abilility 1
Beginner 2
Intermediate 3
AdvancedWritten English 1
Beginner 2
Intermediate 3
AdvancedListening Comprehension 1
Beginner 2
Intermediate 3
AdvancedAdditional comments about the student’s knowledge o English and his/her ability to unction in an English-speaking workplace:Name o Teacher
(Please Print)
:Name o Educational Institution
(Please Print)
:Teacher’s Signature: Date
(DD/MM/YYYY)
:
How did you fnd out about Work & Travel USA?
1
www.ciee.org 5
Other Website:2
CIEE Representative 6
Placement Agency - Name:3
Friends/Relatives 7
Other:4
School/University

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