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J-1 Camp Counsellor Application Form

    Last Name (required):

    First Name (required):

    Middle Name (required):

    E-mail (required):

    Address:

    Contact #:

    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 #:

    Name of Institution:

    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:

    Position held:

    Year 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 Name (required):

    Father's D.O.B.

    Mother's Name (required):

    Mother's D.O.B.

    Give three references

    First Reference Name:

    First Reference Occupation:

    First Reference Address:

    First Reference Contact #:

    First Reference Relation:

    Second Reference Name:

    Second Reference Occupation:

    Second Reference Address:

    Second Reference Contact #:

    Second Reference Relation:

    Third Reference Name:

    Third Reference Occupation:

    Third Reference Address:

    Third Reference Contact #:

    Third Reference Relation:

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