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Program Dates
ICEO USA Summer Work / Travel Program
Participants Application 2017

1 1 7
2 / ___|___ / 20 |___|___
Date of departure to the U.S. (month/day/year): ___|___
Program start date (month/day/year): ___|___ 1 7
1 2 / ___|___ / 20 |___|___ (Must be no more than 30 days after departure date as listed above)

Program end date (month/day/year): ___|___ 1 8


0 3 / ___|___ / 20 |___|___ (Must be no more than 4 months after Program start date as listed above)

(Must be no more than 30 days after Program end date as listed above and no more than
Date of return to home country (month/day/year):___|___
0 3 / ___|___ / 20 |___|___
1 8 five months after the arrival date)

Applicant Details (As they appear in your passport)

Surname: ________________________________________________________________________________________________________
Given name(s): ___________________________________________________________________________________________________
Date of birth (month/day/year): _______________________________________ Gender: Female Male
City of birth: _____________________________________________________________________________________________________
Country of birth: __________________________________________________________________________________________________
Country of citizenship: _____________________________________________________________________________________________
Country of legal permanent residence: ________________________________________________________________________________
Passport number: _________________________________________Passport expiration date (month/day/year):_______________________
Passport issuing country:___________________________________________________________________________________________
Contact Information
Current street address: _____________________________________________________________________________________________
Peru
Postal code:___________________ City:________________________________ Country:______________________________________
Home telephone:( 51 )(1 ) __________________________ Mobile/Cellular:( 51 )(1 ) _____________________________
Email (mandatory):__________________________________________________________________________________________________
Secondary address (check if same as above): or Valid after (month/day/year): ___|___ / ___|___ /20|___|___
Street address: ___________________________________________________________________________________________________
Postal code:___________________ City:________________________________ Country:______________________________________
Emergency Contact
Surname: ________________________________________________ Given name(s): __________________________________________
Relationship to applicant: ___________________________________________________________________________________________
Current street address: _____________________________________________________________________________________________
Postal code:___________________ City:________________________________ Country:______________________________________
Home telephone:(51 )(1 ) __________________________ Mobile/Cellular:( 51 )( 1 ) _____________________________
Email:___________________________________________________________________________________________________________
Previous Visas (If you have previously received more than one J-1 visa, please provide the same information requested below on a seperate sheet of paper)
Have you ever received a J-1 visa to enter the USA? yes no If yes, how many times? ____________
If yes, please complete the following for each previous J-1 visa:
Program category: _________________________________________________ Sponsors program number: ________________________
Name of sponsoring organization: ____________________________________________________________________________________
Dates of previous program (dates from DS-2019 form): from (month/day/year):__________________ to (month/day/year): __________________
*Have you ever been convicted of a crime in the United States or your home country? yes no
*Have you ever applied for a visa to emigrate permanently to the United States? yes no
*Have you ever been refused a visa by a United States Embassy? yes no
*Have you ever been denied entry into the United States? yes no
*If you have answered yes to any of these questions, please provide a written explanation and attach to your application.

Additional Information
How did you learn about the ICEO Program?
Website (www.iceoinc.org) Advertisement Friend Television Internet
Social Media Other: ACE PERU Agency
____________________________________

International Cultural Exchange Organization Inc. / 11931 Foundation Place, Suite 220, Gold River, CA 95670 / Phone: (916) 985-4826 / Fax: (916) 985-9922 / www.iceoinc.org Page 1
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Post Secondary Education Details
ICEO USA Summer Work / Travel Program
Participants Application 201

Name of Institution: _______________________________________________________________________________________________


Type of Institution: ________________________________________________________________________________________________
Major: ___________________________________________ Total course length of your Major (total in years):______________________
Address: ________________________________________________________________________________________________________
PERU
Postal code:___________________ City:________________________________ Country:______________________________________
Telephone:( )( ) ___________________________________ Fax:( )( ) ___________________________________
Website:_________________________________________________________________________________________________________

At the time of completing this application, how many full semester(s) of study will you have completed? _____________
At the time of your departure to the U.S., how many full semester(s) of study will you have completed? _____________
Upon departure to the United States will you be a full-time university student? yes no
Upon returning to your country of residence will you be a full-time university student? yes no

(This section must be completed by an accredited ocial from your academic institution. If your academic institution will
Proof of Student Status not sign this form, you must attach an ocial letter on academic institution letterhead confirming the same information.)

I hereby certify that the below named applicant is registered in the above-named institution as a full-time student for the academic year
2017
of _________ and is currently pursuing classroom-based academic studies at our university / institution. Our ocial university / institution
break between academic years is from (month/day/year) ______________ to (month/day/year) _______________.

ICEO Program applicants name: _____________________________________________________________________________________

Accredited ocials name (completing form):___________________________________________ Title: ______________________________

Telephone: ( )( ) ______________________________ Email: _____________________________________________________

Ocials signature: __________________________________________________ please place university


stamp / seal
Date (month/day/year): _________________________________________________ here

Proof of English Language Ability (This section must be completed by an English teacher / instructor.)

Oral English Beginner Intermediate Advanced


Written English Beginner Intermediate Advanced
Listening Comprehension Beginner Intermediate Advanced

Additional Comments:______________________________________________________________________________________________
ACE PERU STAFF
Name of teacher / instructor:________________________________________________________________________________________
ACE PERU
Name of educational institution:______________________________________________________________________________________
Teachers / instructors signature:_____________________________________________ Date (month/day/year):______________________
Proof of Sucient Funds
Applicants must show evidence that they will be able to support themselves during their entire stay in the U.S. (duration of Program plus
travel dates). Applicant must have a minimum of $800.00 ($1,500.00 for applicants choosing Unplaced Program Option*) in personal
funds while traveling to the United States.
By checking this box I (surname, given name(s))______________________________________________certify that: 1) I understand that I
must be able to support myself upon my arrival in the U.S. until such time when I receive my first paycheck; 2) The minimum amount that
I will be taking with me to the U.S. in personal funds is $800.00 ($1,500.00 for applicants choosing Unplaced Program Option*); and 3) I
have access to additional funding as necessary.
I also have attached one of the following documents indicating that I have access to the required funds:
a) An original bank statement or certified copy of the bank statement; or
b) A letter from a guarantor.
*Unplaced Program Option is only available to Nationals of Visa Waiver Program countries who arrive to the United States without secured employment.

International Cultural Exchange Organization Inc. / 11931 Foundation Place, Suite 220, Gold River, CA 95670 / Phone: (916) 985-4826 / Fax: (916) 985-9922 / www.iceoinc.org Page 2
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Program Budgeting (Please enter all amounts in US Dollars.)
ICEO USA Summer Work / Travel Program
Participants Application 201

1. Program Income and Personal Funds:


a. Personal Funds which you intend to bring with you to the United States: .................. $ ____________
b. Wage: (number of hours per week x number of weeks x hourly wage) based on the information from your Employment
Confirmation Letter***: ...................... $ ____________
Total Amount = $ ____________
2. Expenses connected with your participation in the ICEO Program:
a. Total Program Fee paid to your recruitment agency in (country)_____________________________________:.... $ 1500
____________
b. Round trip air-ticket from your home country to the USA*: .......... $ 900
____________
c. USA Consulate Fees: ........ $ 160
____________
d. Total cost of accommodation in the United States during the program*: ......... $ ____________
e. Total cost of basic household goods during the program**: .......... $ 200
____________
f. Total cost of daily commute during the program*: ............ $ 150
____________
g. Total cost of food during the program**: ......... $ 900
____________
h. Cost of other daily essentials during the program**: ....... $ 150
____________
i. Cost of entertainment during the program**: ........ $ 200
____________
j. Cost of participation in cultural activities*: .......... $ 200
____________
k. Cost of other domestic transportation during the program**: ......... $ 150
____________
l. Cost of travel after the program*: ............. $ ____________
m. Emergency medical fund (insurance deductible): ............. $ 200
____________
* Can be an approximate amount.
Total Amount = $ ____________
** The ICEO Program Participant handbook can be used to estimate this value.
*** Information available for self-placed and ICEO placed participants only.

3. Anticipated financial balance at the end of the program (Total Amount from # 1 minus Total Amount from # 2.): ...... $ ____________

Additional Information (If additional space is needed, please include answers on a seperate sheet of paper and attach to this application.)

1. How will you finance your participation in the ICEO Program? personal funds funds from parents/family bank loan
other ______________________________
2. Why do you want to take part in the ICEO Program?
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
3. What do you hope to achieve by participating in the ICEO Program?
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
4. Do you have any friends or relatives currently living in the United States? yes no
If yes; a) what is your relationship to this person(s) and; b) where are they living and for how many years?
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
5. Please provide a detailed description of how you intend to spend your time in the United States during the ICEO Program?
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________

International Cultural Exchange Organization Inc. / 11931 Foundation Place, Suite 220, Gold River, CA 95670 / Phone: (916) 985-4826 / Fax: (916) 985-9922 / www.iceoinc.org Page 3
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Additional Information - continued
ICEO USA Summer Work / Travel Program
Participants Application 201

(If additional space is needed, please include answers on a seperate sheet of paper and attach to this application.)
6. Please provide a detailed description of your plans to participate in Cultural Activities during the ICEO Program (generic answers will not
be accepted).
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
7. Please provide a detailed plan on how you are going to transfer from the Airport to your host companys location after arrival to the
United States.
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
8. Please provide a detailed plan on how you are going to identify and secure local daily transportation during your ICEO Program.
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
9. Please provide a detailed plan on how you are going to identify and secure housing during your ICEO Program (If housing is arranged by
your host company, please note Housing arranged by host company below; If housing is not arranged by your host company, please
answer the question that applies to you below).
a. If you have not yet identified and secured your housing, please provide detailed housing plans (generic answers will not be accepted).
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
b. If you already identified and secured your housing, please provide the following details.
i. How did you arrange this housing?
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
ii. Housing information
Address of housing:
Security deposit (per participant / tenant): Type of housing:
Cost per week (per participant / tenant): Number of bedrooms:
Other fees: Number of tenants:
Furnishings / amenities included:
Specify utilities included and not included:
How are the above fees collected?
Will you be required to sign a lease or sublease? yes no
*If yes, please attach a copy of the lease or sublease agreement to be signed (if available).
**Please attach photos of housing: Exterior, Bedrooms, Common Area, Bathroom and Kitchen.

International Cultural Exchange Organization Inc. / 11931 Foundation Place, Suite 220, Gold River, CA 95670 / Phone: (916) 985-4826 / Fax: (916) 985-9922 / www.iceoinc.org Page 4
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Terms and Conditions
ICEO USA Summer Work / Travel Program
Participants Application 201

The following are the Terms and Conditions of participation in ICEO USA Summer Work / Travel Program. You are required to carefully read the following information, and
confirm that you have read, understood and agree to these terms by signing and dating the last page. If you fail to sign or date this section, ICEO will be unable to process
your application until you have done so.

Applicant/Participant Responsibilities conditions of such employment and fully vetted the U.S. employer as
17. Participant is required to comply with all U.S. Government visa and
1. Each applicant agrees that all the information provided by participant immigration requirements, including SEVIS compliance as follows: a) required by Summer Work Travel program regulations. Programs of
to ICEO, ICEO Partner or U.S. government as part of the application or as Notification to ICEO of arrival to the United States within 10 days of the participants who begin employment prior to (i) the approval by ICEO of
necessary for participation in the ICEO USA Summer Work /Travel arrival but no later than 20 days from the Program start date listed on the the U.S. employers, or (ii) the approval by ICEO of the position with an
Program (Program) is true to the best of his/her knowledge, and participants DS-2019 Form and confirmation of his / her U.S. residence approved U.S. employer will be immediately terminated by ICEO.
acknowledges that any false or misleading information may lead to address; b) Notification to ICEO of any change in U.S. residence address 24. Participant is required to maintain communication with ICEO and
immediate dismissal from the Program. The terms applicant and within 10 days of the change; c) Providing ICEO with a valid e-mail his/her U.S. employer prior to arrival, notify ICEO and U.S. employer in
participant are used throughout these terms and conditions to refer to address and phone number upon arrival to the United States; d) advance of his/her arrival and departure dates, and advise ICEO and U.S.
the person who has completed and submitted this application for Notification to ICEO of any change in phone number or e-mail address employer of any changes to his/her travel itinerary due to visa delays or
participation in the Program. within 10 days after the change. ICEO will terminate participants any unforeseen circumstances.
2. The applicant acknowledges the aims and objectives of the Program as Program if he/she fails to comply with any of the above Program 25. Under no circumstances are job positions guaranteed including,
a U.S. Department of State authorized Exchange Visitor Program, with notification requirements. without limitation, any job with an ICEO-arranged U.S. employer. Even in
the purpose of providing qualified individuals with cultural exchange 18. Participant must have at least $800.00 upon arrival in the U.S. in order the case when an employer represents that a job is being held, this does
opportunities in the United States. to support himself/herself in the U.S. until receiving his/her first not constitute a binding contract that the job will be available when the
3. The applicant is responsible for considering his/her personal health paycheck. However, a participant who is a national of a Visa Waiver participant arrives. The employers commitment is one of good faith
and safety needs when applying for or accepting a place in the Program. Program country and who has not secured a job prior to arriving in the only. In addition, if the participant is not fluent in English and/or does
If the applicant suers from any health or other condition that would U.S. must have at least $1500.00 upon arrival in the U.S. not arrive on time and/or has misrepresented any statement in the
create a risk for him/her while abroad, he/she should not apply. 19. Participant is solely responsible for his/her own conduct and well- application, participant may be terminated from the Program or the
4. The participant is responsible for reading and carefully considering all being both on and o the job. ICEO cannot and does not monitor the positions may be revoked by the U.S. employer. In addition, if the
materials made available to participant that relate to the term and participants personal conduct, except to the limited extent indicated in participant does not meet the contractual obligations with the employer
conditions of the Program; all U.S. government rules and regulations this Terms and Conditions. Participant must follow all U.S. Federal, state or with ICEO under any agreement between such party and participant,
regarding the Program; and all safety, health, legal, environmental, and local laws, rules, statutes, ordinances and regulations (Laws) and ICEO, at its sole discretion, may terminate the participants participation
political, cultural and religious customs and conditions in the U.S.. Each may be subject to financial penalties, deportation and/or incarceration as in the Program.
participant will be responsible in the event that any term, condition, laws, a result of not following such Laws. 26. ICEO is not responsible for any participant expenses including,
regulations, or customs are broken including, without limitation, these without limitation, any expenses incurred if for any reason the
Employment or Job Related Conditions participant has not started work with the U.S. employer by the agreed
Terms and Conditions, regardless of foreknowledge.
5. The applicant agrees to pay all fees in accordance with the date for any reason at his/her place of employment and/or the work
20. Regardless of who arranges the employment placement, participant
requirements of the ICEO in-country partner through whom he or she is hours are limited or unavailable.
can only be placed in employment positions which require, at minimum,
submitting an application (ICEO Partner). 27. Once a participant accepts a position with a U.S. employer,
no more than minimal training, are seasonal or temporary in nature,
6. The applicant is responsible for submitting all requested documenta- participant agrees to stay at that place of employment for the duration
provide opportunities for regular communication and interaction with
tion (including passport) to the ICEO Partner in a timely fashion for visa of the Program. If participant wishes to leave the position after
U.S. citizens, allow participant to experience U.S. culture and not displace
processing. ICEO cannot be held responsible for any additional costs participant starts work or declines to start work after accepting a
year-round U.S. workers. ICEO reserves the right to deny any
incurred (including the cost of rebooking a flight) by the applicant due to position, participant must immediately notify ICEO in writing and must
employment placement according to the current and/or anticipated
delays in submitting documentation, verifying employment, or delays obtain ICEOs written permission prior to leaving the U.S. employer. If
rules, regulations, and intent of the J-1 Exchange Visitor program.
caused by the U.S. Embassy in processing visa applications, scheduling a participant does not receive prior written approval to change positions
Relevant factors include, but are not limited to, the job duties, workplace,
visa interview, issuing a visa, or visa denial. from ICEO, and if participant leaves this employment without the prior
geographical location, work schedule, and hours per week and any other
7. Applicant must pay the local visa fee to the U.S. Embassy. Applicant is written approval of ICEO, ICEO reserves the right to immediately revoke
factor at ICEOs discretion.
responsible for any additional visa fees that might apply at the U.S. sponsorship of participants Program.
21. Regardless of who arranges the employment placement, ICEO cannot
Embassy or Consulate in the country where he/she is applying for the 28. No person or entity other than ICEO, ICEO Partner or participant is
accept applications from participants for, and participants are prohibited
visa, as well as the U.S. Government SEVIS fee collected as part of the allowed to arrange for an employment position for participant as the
from working in, any of the following positions in the U.S.:
application. part of the Program.
(a) In positions that could bring notoriety or disrepute to the Exchange
8. Applicant must attend an interview with an ICEO representative and/or 29. For those employment positions arranged by ICEO with U.S.
Visitor Program as determined by ICEO;
ICEO either in-person or by video-conference and complete language employers, if the position is not available, through no fault of
(b) In sales positions that require participants to purchase inventory that
screening in order to participate in the Program. participant, ICEO will assist the participant in finding another position
they must sell in order to support themselves;
9. Participant is required to attend an ICEO orientation prior to leaving with a U.S. employer. However, ICEO makes no guarantee that it will be
(c) In domestic help positions in private homes (e.g., child care, elder
his/her home country. able to secure another position for participant. If a new position is
care, gardener, chaueur);
10. It is the responsibility of the participant to exercise due care once in available, it is likely the position would not be in the same geographical
(d) As pedicab or rolling chair drivers or operators;
possession of the legal documentation (DS- 2019, Passport and Visa). The area or of the same type of work the participant had previously or
(e) As operators or drivers of vehicles or vessels for which drivers licenses
cost of replacing these items will be the responsibility of the participant. prefers.
are required regardless of whether they carry passengers or not;
In addition, the participant is responsible for providing to ICEO all 30. For those employment positions not-arranged by ICEO with U.S.
(f) In positions related to clinical care that involves patient contact;
information necessary for ICEO to activate participants Program status in employers, if the position is not available, through no fault of
(g) In any position in the adult entertainment industry (including, but not
SEVIS. All costs associated with any Program reinstatements will be participant, it is participants responsibility to identify another
limited to, jobs with escort services, adult book/video stores, and strip
borne by the participant. employment position. However, in such situations, ICEO will oer
clubs);
11. Participant is responsible for all the costs associated with processing reasonable assistance to participant in their eort to identify another
(h) In positions requiring work hours that fall predominantly between
and shipping Travel Request Forms. position. ICEO cannot guarantee that a new position will be available.
10:00 p.m. and 6:00 a.m.;
12. Participant must supply ICEO with the name and contact details of 31. In case of change of job or of premature termination of job, or if the
(i) In positions declared hazardous to youth by the Secretary of Labor at
next of kin, to be contacted in the case of emergency. These details must employment is terminated before the end of the Program for any
Subpart E of 29 CFR part 570;
be included on the application form and be kept current during the reason, or if the participant decides to return home early, no fees will be
(j) In positions that require sustained physical contact with other people
Program. refunded.
and/or adherence to the Centers for Disease Control and Preventions
13. Participant is responsible for all of his / her acts along with any loss or 32. If a participant is fired from his or her job for violation of a Law or
Universal Blood and Body Fluid Precautions guidelines (e.g., body
damage resulting there from while on the Program. The participant violation of U.S. employer policies or procedures, including failing a U.S.
piercing, tattooing, massage, manicure);
agrees to indemnify and hold harmless ICEO for any claim, liability or loss employer required drug test at the commencement or anytime during
(k) In positions that are substantially commission-based and thus do not
arising from, related to or resulting from directly or indirectly employment, or if participant violates any ICEO agreement, rule or
guarantee that participants will be paid minimum wage in accordance
participants conduct. policy, participant will be terminated from the Program and no fees will
with federal and state standards;
14. All travel before, during and after the Program is at the participants be refunded.
(l) In positions involved in gaming and gambling that include direct
own cost and risk. Any participant who chooses to operate a motorized 33. If participants job ends before the end date on the DS-2019 Form
participation in wagering and/or betting;
vehicle is responsible for obtaining the necessary license, permission and (Program end date) for any reason other than disciplinary actions by U.S
(m) In positions in chemical pest control, warehousing, catalogue/online
insurance and does so at his/her own risk. employer or ICEO but including if the participant voluntarily stops work,
order distribution centers;
15. If during the course of the Program the participant encounters any participant must inform ICEO immediately. In such an event the
(n) In positions with travelling fairs or itinerant concessionaires;
diculties with any element of the Program such as issues concerning following options are available to participant:
(o) In positions for which there is another specific J visa category (e.g.,
safety, health, employment, housing (including charges or fees for A) If participant decides to identify a new U.S. employer for the
camp counselor, intern, trainee);
housing) sanitary conditions, over crowding, or any other problem, the remainder of the Program, the new U.S. employer must be approved by
(p) In positions in the North American Industry Classification Systems
participant should notify ICEO as soon as possible by phoning ICEO at 1- ICEO prior to participant beginning work for the new U.S. employer as
(NAICS) Goods-Producing Industries occupational categories industry
916-985-4826 during business hours or in an emergency at 1-877-423- described in point 23 of this Terms and Conditions. Participant must
sectors 11, 21, 23, 3133 numbers (set forth at
6462, 24 hours a day, 7 days a week. identify new U.S. employer and ICEO must be able to approve both the
http://www.bls.gov/iag/tgs/iag_index_naics.htm).
16. A schedule of monthly meetings between participant and an ICEO new U.S. employer and the oered employment position within 21 days
(q) In positions in a stang agency;
representative will be provided to participant prior to participants from the last date of employment with the previous U.S. employer. If
(r) In positions that require participant to obtain or hold a specialized
departure to the U.S. The monthly meetings will be conducted in-person, participant fails to identify a new U.S. employer or ICEO is unable to
license; or
by telephone, or via electronic mail at ICEOs direction. The monthly approve the identified new U.S. employer or oered employment
(s) In any other position ICEO deems inappropriate.
meetings are mandatory and missing monthly meetings will lead to position within the allotted 21 days, ICEO will complete participants
A complete list of prohibited employment positions is available from ICEO
participants termination from the Program. Participant must notify ICEO Program at the end of the allotted 21 days, if applicable. In addition,
upon request.
of any issues aecting participants health, safety, or welfare during this within 72 hours from the last date of employment with the previous U.S.
22. Participant must work for the employer listed on their DS-2019 Form.
monthly contact. Once a month, participant must also complete Monthly employer, participant must provide ICEO with proof of sucient
If, for any reason, a change of employer becomes necessary, participant
Activity Report available on line at www.iceoinc.org. Participant agrees to financial resources to support himself/herself during the search for
must contact ICEO and get written approval BEFORE changing employers.
respond in a timely manner to any ICEO communication requiring a employment. If participant is unable to provide proof of sucient funds
23. Participant may not begin working at initial, replacement or
response. within the allotted 72 hours, ICEO will complete participants Program at
additional jobs with a U.S. employer until ICEO has verified the terms and
the end of the allotted 72 hours.
iceo
Terms and Conditions
ICEO USA Summer Work / Travel Program
Participants Application 201

B) If participant decides to spend the remainder of the Program involved 40. The conduct, operation and rules of the ICEO USA Summer event that a participant has failed to secure adequate insurance.
in Cultural Exchange Activities (including travel), participant must provide Work/Travel Program is subject to U.S. government approval and may Information on insurance provisions can be obtained from ICEO.
ICEO within 72 hours from the last date of employment with the change without notice. 51. Under the U.S. governments Health Insurance Portability and
following items: proof of sucient financial resources to support 41. Any and all entities (other than ICEO) which provides any goods or Accountability Act (HIPAA), ICEO is restricted in its access to certain
himself/herself during the Cultural Exchange Activities, and a plan of services to or for a participant with respect to the Program including ICEO medical information or records in the event that a participant has an
Cultural Exchange Activities including participants travel itinerary. If Partner (e.g. organizations providing housing arrangements, transporta- accident in the U.S.. In order for ICEO to assist participant to the fullest
participant is unable to provide the required information within the tion companies and food service or entertainment providers) are either extent possible with any questions or issues which may arise relating to
allotted 72 hours, ICEO will complete participants Program at the end of independent contractors of ICEO or have contracted directly with participants health or insurance, ICEO will need to have a signed Privacy
the allotted 72 hours. Maximum duration of those Cultural Exchange participant and are not owned by, related to or under the control of ICEO. and Confidentiality Release Form from the participant. This form is
Activities and travel is 21 days. ICEO will complete participants Program As a result, ICEO is not liable for any negligent or willful act or failure to optional and the participant can choose whether or not to grant ICEO
at the end of 21 days, if applicable. act of any such person or entity, or of any third party. access to this information. This release form and additional information
34. If after the arrival to the United States participant does not report to 42. ICEO is not responsible for any injury, loss, or damage to person or about the HIPAA requirements are included as part of the Program
his/her original ICEO approved U.S. employer, travels to a dierent property, death, delay or inconvenience resulting from any act beyond its application packet. If you did not receive this information or release
location in the United States or attempts to immediately change U.S. direct control including, without limitation, any acts of God, force form please contact the ICEO Partner.
employers, ICEO will terminate participants Program. majeure, acts of war or civil unrest, insurrection or revolt, strikes or other 52. ICEO reserves the right to dismiss from the Program any participant
35. Participant who is a national of Visa Waiver Program country and who labor activities, criminal or terrorist activities of any kind, overbooking or who is deemed by ICEO to be a danger to himself/herself or others or
has not secured a job prior to arriving in the U.S. must notify ICEO after downgrading of accommodations, structural or other defective whose conduct is deemed to be detrimental to the Program. In the event
one week of commencing job search, if participant has not found suitable conditions houses, apartments or other lodging facilities (or in any of such a dismissal or termination of the participant in the Program for
employment. In such case ICEO will oer reasonable assistance to heating, plumbing, electrical or structural problem therein), mechanical any reason once the participant has left his/her home country, ICEO shall
participant in their eort to identify a Program suitable employment or other failure of airplanes or other means of transportation or for any not be held responsible for any airfare, charges or any other expense
position. If such participant is unable to identify employment and have failure of any transportation mechanism to arrive or depart timely, incurred by the participant, and shall not be required to return any fees
the employment approved by ICEO within 21 days from the arrival in the dangers associated with domestic or wild animals, sanitation problems, paid by the participant.
United States the following rules will apply: food poisoning disease, lack of, access to or quality of medical care, 53. ICEO does not provide housing for participant nor is ICEO responsible
A) Participant may continue searching for suitable employment for an diculty in evacuation in case of medical or other emergency. for participants housing. If a U.S. employer does oer housing to
additional 21 days. Participant must identify U.S. employer and ICEO 43. The participant agrees that any dispute between participant and ICEO participant, the housing arrangement is between participant and the
must be able to approve both the U.S. employer and the oered arising out of or relating to participants involvement in the Program, U.S. employer and is usually on a first-come, first-served basis.
employment position within this additional 21 days. If participant fails to Program Participant Application, these terms and conditions, or any Participant must notify ICEO immediately if he / she has any concerns
identify a new U.S. employer or ICEO is unable to approve the identified other literature concerning the Program, must be brought or filed in regarding the safety or suitability of the housing provided by his / her
new U.S. employer or oered employment position within the allotted either a state or federal court located in California, and each of the U.S. employer. If U.S. employer does not provide housing for participant
additional 21 days, ICEO will complete participants Program at the end of parties consents to the jurisdiction of such courts and waives any or if participant rejects U.S. employer-oered housing, ICEO will oer
the allotted additional 21 days, if applicable. In addition, within the first objection to venue laid therein. Process may be served on any party reasonable assistance to participant in locating Program suitable
24 days from the arrival to the United States, participant must provide anywhere in the world. housing though participant shall at all times be responsible for securing
ICEO with proof of sucient financial resources to support housing while in the U.S. If the participant arranges housing
himself/herself during the search for employment. If participant is unable ICEO Program-Related Conditions independently, he/she agrees to use his/her best judgment in securing
to provide proof of sucient funds within the allotted time, ICEO will housing that is safe and suitable. Housing arrangements that involve
44. ICEO reserves the right to refuse sponsorship of any applicant that
complete participants Program at the end of the allotted time. overcrowding and/or hot-bunking (multiple individuals using one bed
ICEO deems does not meet the Program eligibility requirements or any
B) If participant decides to spend the remainder of the Program involved and sleeping in shifts) are strictly prohibited. If the participant has any
applicant that ICEO does not deem appropriate to accept in the general
in Cultural Exchange Activities (including travel), participant must provide doubt about the suitability of his/her housing, he/she must notify ICEO
interests of the Program. In the event that ICEO refuses acceptance of an
ICEO within 24 days from the arrival to the United States with the immediately. Whether the participant arranges housing independently
applicant to the Program, any available refund will be made via the ICEO
following items: proof of sucient financial resources to support or through the U.S. employer, the participant should be aware that
Partner through whom the original application was submitted.
himself/herself during the Cultural Exchange Activities and a plan of he/she will likely be required to sign a lease with the landlord or U.S.
45. Participation in the Program begins when the participant legally
Cultural Exchange Activities including participants travel itinerary. If employer and pay to the landlord or U.S. employer a deposit usually in
enters the U.S. and terminates on the day of departure from the U.S.
participant is unable to provide the required information within the an amount equal to the first and last months rent. The deposit also may
(within the legal Program dates) unless terminated or completed earlier
allotted time, ICEO will complete participants Program at the end of the include an additional security deposit.
by ICEO. The maximum Program duration is 4 months. Participant can
allotted time. Maximum duration of these Cultural Exchange Activities 54. Notwithstanding any other provision of these terms and conditions
arrive 30 days prior to their DS Program start date and remain in the U.S.
and travel is 21 days. ICEO will complete participants Program at the end or the application, participant is not and never shall be an employee of
up to 30 days beyond their DS Program end date, as long as participants
of these 21 days, if applicable. ICEO. U.S. employer shall be the exclusive employer of participant. Any
stay in the U.S. does not exceed the shorter of (a) a total of 5 months, or
employment questions, concerns, issues or problems should be
(b) participants ocial summer break from their home country
Cultural Exchange Activities addressed by participant first directly with U.S. employer. If such
university. Participant understands that he/she is expected and must
questions, concerns, issues or problems are not resolved with U.S.
36. Participant must actively participate in cultural activities during the return to their home country in time for the start of their university
employer, participant should notify ICEO. ICEO shall in no event or
Program including, but not limited to, daily interactions with US citizens classes. Extensions of Program participation are not permitted.
circumstance be responsible for any actions or inactions of U.S.
during and outside of work, local community involvement, sightseeing 46. ICEO may issue a DS-2019 form if a participant meets the Program
employer.
and participation in cultural events. Participant must document all of requirements, but cannot guarantee that the U.S. Embassy or Consulate
55. ICEO reserves the right to provide participant with information ICEO
his/her cultural activities and report them to ICEO as a part of the in a participants country of residence will issue a J-1 visa even if
deems useful to participants, including but not limited to tax, travel and
Monthly Meetings and the Monthly Activity Reports. Participant must participant meets the Program requirements or if participant has been
related services. In signing below, participant authorizes ICEO to provide
take part in at least one selected ICEO organized cultural activity, if accepted into the Program by ICEO.
the participants contact information to third parties who provide useful
available in the location of participants Program. List of ICEO organized 47. Once a participant has commenced his/her travel to the U.S., ICEO
services to participants. Third parties receiving this information will be
cultural activities will be provided to participant by either ICEO Partner or cannot amend the Program dates as listed on the DS-2019 for any reason.
required to provide the participant with the opportunity to opt out after
ICEO. It is the participants responsibility to check prior to travel that the dates
the first contact. The participant gives ICEO permission to use any
are correct.
General Terms written, photographic, or video images of himself/herself in the course
48. Once the participant received the J-1 visa associated with the
of reporting on and/or promoting ICEO programs.
Program, there will be no refund by ICEO for any reason including,
37. This English language version of the Terms & Conditions is the binding 56. If ICEO deems, in its sole discretion, or if it is advised by the State
without limitation, should the participant leave the Program or should
contract between the participant and ICEO and shall control over any Department that a participants housing and/or work placement is
ICEO withdraw its sponsorship.
translation of these Terms & Conditions into another language even if unsafe or unsuitable, participant agrees to cooperate fully with ICEO to
49. Applicants who have recently held a J-1 visa for the U.S. may have to
such translation was provided to participant by ICEO or ICEO Partner. relocate to new housing and/or work placement without delay. Failure
remain in their home country for a minimum of 90 days before ICEO can
38. ICEO makes no representation or warranty of any kind, expressed or to cooperate may result in action by ICEO up to and including
issue a DS-2019 Form for the Program. Any such applicants should
implied, as to the suitability of the Program for any participant and ICEO termination of a participants Program and requiring the participant to
immediately contact the local ICEO Partner and local U.S. Embassy for
disclaims all such warranties to the full extent of the law. return home immediately.
details.
39. The participant understands that perceived or actual epidemics (such 57. ICEO reserves the right to utilize publicly available information,
50. Insurance is provided for each participant for the dates confirmed by
as, but not limited to, SARS or bird flu) can seriously disrupt, interrupt, or including social media, which has not been directly provided to ICEO by
ICEO, by an outside insurance company, as a mandatory part of the
cause the cancellation of entire programs. The participant agrees to the participant. Information obtained through these means can be used
Program. It is the responsibility of each participant to purchase additional
assume all risks and losses (including financial) that result from any such as a basis for any decisions made by ICEO aecting the participants
insurance should they extend their period abroad for any reason. ICEO
occurrence. Program.
cannot be held responsible for any injury, loss or insurance claim in the

Applicant Signature

I have read, understood and agree to all terms outlined in the ICEO USA Summer Work / Travel Program participation Terms and Conditions.
Additionally, by signing below, I also confirm that, to the best of my knowledge, all information contained in this Program Application is true
and accurate.

Print Name: _____________________________________________________________________________________________________


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Signature: ______________________________________________________ Date (month/day/year):___|___ 1 7
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International Cultural Exchange Organization Inc. / 11931 Foundation Place, Suite 220, Gold River, CA 95670 / Phone: (916) 985-4826 / Fax: (916) 985-9922 / www.iceoinc.org Page 6