J-1 Summer Work & Travel Application Form

Last Name (required):

First Name (required):

Middle Name (required):

E-mail Address (required):

Home Address (required):

Contact # (required):

D.O.B.

Skype ID (required):

Number of Dependent (s):

Nationality:

Age:

Gender:
MaleFemale

Upload Your Resume/CV

Upload Your School ID

Upload Your Passport Information Page

Upload Your Passport Size Picture

Upload Your Certified Status Letter

Passport #:

Passport Expiration Date:

Passport Issue Date:

Social Security # (or Tax Registration #):

Institution Attended:

Address of Institution:

Field of Study:

Year of Study:

1st2nd3rd4th5th

Expected Date of Completion:

Name and address of high school attended:

Year started:

Year ended:

What option are you applying for?

Self-PlacementFull Placement

Give two job preferences in the space below:

Have you ever participated in this program before?

YesNo

If yes, state where:

Sponsor Name:

Position held:

Number of Year(s) participated:

Would you like to work at the same location as a friend?

YesNo

If yes, please give your friend’s name:

Do you have any family and/or friends in the USA?

YesNo

If yes, please state their names, relationship and address:

Status of immediate family in the USA:

Have you ever been denied a US visa?
YesNo

Have you ever lost a passport?
YesNo

Have you ever been convicted of a crime?
YesNo

If yes, explain:

Do you have any serious illnesses and/or allergies?
YesNo

If yes, specify:

Marital Status:

SingleMarriedOther

Spouse's Full Name:

Spouse's D.O.B.

Who will pay for your trip?

Address of person paying for your trip:

Next of Kin/Emergency Contact Name:

Next of Kin/Emergency Contact Address:

Next of Kin/Emergency Contact #:

Next of Kin/Emergency Contact Email Address:

Next of Kin/Emergency Contact Relation:

Father's Full Name (required):

Father's D.O.B.

Mother's Full Name (required):

Mother's D.O.B.

Give three references

First Reference Full Name:

First Reference Occupation:

First Reference Address:

First Reference Contact #:

First Reference Relation:

Second Reference Full Name:

Second Reference Occupation:

Second Reference Address:

Second Reference Contact #:

Second Reference Relation:

Third Reference Full Name:

Third Reference Occupation:

Third Reference Address:

Third Reference Contact #:

Third Reference Relation:

Connect with us on social media by following @jobseekersjipa!!!

Are you on social media?
YesNo

If yes, list social media accounts usernames so that we can connect with you:

I agree that the information given is true to the best of my knowledge.

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