Summer Work Travel Program Application 2012

Passport Details (copy exactly as in passport) Family Name First Name Date of Birth (Month/Day/Year) City of birth Country of citizenship Passport Number Contact details Permanent Address (Parental home) City Home phone University Information Name of University Length of course Previous Visa Information Have you had a previous Summer Work Travel J-1 visa? How many years have you completed? Field of Study Are you enrolled full-time? Region Mobile Phone Postcode Email Country Middle Name(s) Age Country of Birth

Male Female

PLACE PHOTO HERE

Country of legal permanent residence Date of issue Date of Expiry

Yes No

Yes

No

If yes, how many?

Please list the years of your previous J-1 visa and who your sponsor was (Year / Sponsor).

Yes. Please explain. Yes. Have you ever been arrested or convicted of a crime? No
Have you ever been refused a visa? Employment Estimated Job Start Date: Have you worked before? Job 1 Company City, State, Country Give job title and describe duties and responsibilities Supervisors name

No

Please explain.

Estimated Job End Date:

Yes No

If yes, please complete below.

Have you had a J-1 visa before? Dates of employment

Yes No

Supervisors phone number

Job 2 - Company City, State, Country

Dates of employment Supervisors name Supervisors phone number

Give job title and describe duties and responsibilities

Please list the languages you speak and your level of fluency (beginner, early intermediate, intermediate, upper intermediate, fluent).

Driving:

Office use only:

I do not have a driving license.

I have an International drivers license I have a home country drivers license.

Friends Group

Updated October 2010

Name:
Emergency Contact Name of emergency contact Address of Emergency contact Telephone Mobile Email Relationship to you

Personal Information Please answer in full. The information here will be used to assess your English language skills and to determine your job placement (if applicable) Why do you want to work in the USA?

What personal qualities and skills can you offer an employer?

What are your interests and hobbies?

What makes you different from other people?

If you have worked before, what did you enjoy about the job?

Are there any jobs that you would or would not like to have and why?

Living and working in the USA is not always easy. What do you think will be the hardest part? How will you deal with this?

If things dont go the way you expected, how will you handle this? What is your Plan B?

Give an example of a difficult situation that you have dealt with in the past.

What travel have you have done in your home country or abroad?

How have you prepared for your trip to the USA?

Do you agree to take at least $US600 with you to the USA if you have a pre-arranged job ($1000 without a pre-arranged job)?

Yes No

I declare that all the statements and information provided on this application are true. I understand that any false declaration may result in losing my place on the Summer Work Travel Program with no entitlement to a refund or of consequent expenses. Signature Date

Updated October 2010

By initialing the following important Terms and Conditions I ______________________________, have read, understood and agree to the following: THE PROGRAM 1 2 3 4 5 6 7 8 9 10 11 12

Summer Work Travel Program Terms and Conditions 2012

Terms and Conditions
I am a full-time student pursuing a university degree in my home country. The passport information that I have provided is correct. If my DS-2019 is printed incorrectly due to information provided by me, I agree to pay $30 plus courier fees for a replacement. If my passport details change, I will notify my agency and IENA immediately. I possess and can show proof of at least US$600 that I will bring to the USA to be used to support myself during the first month. I understand that this is the minimum required and that IENA recommends that I bring US$1000. I will inform my agent immediately if my planned date of entry to the US changes forwards or backwards. A change in my arrival date may require a change in my DS-2019; if applicable, I will pay $30 plus courier fees for a new DS-2019. If I cancel from the program, I agree to notify my agency & IENA and return the DS-2019 no later than the end-date of the DS-2019. I understand that a pre-departure orientation is required for all first-time Summer Work Travel Program participants and I will attend. I understand that IENA is my visa sponsor, issues the DS-2019 and is responsible for the program operation. I understand that IENA is responsible for providing support services in the USA. If I have questions or experience problems during my program participation, I can call the freephone number 1-347-560-1789 for help. I understand that IENA reserves the right to close the program at short notice or to cancel anyone from the program if a situation arises where this is necessary. If IENA cancels an application, no charge applies. I agree to behave ethically and responsibly while in the USA. I understand my DS-2019 and insurance can be cancelled at the discretion of IENA if I behave in a way that is in violation of the program rules or can be considered to be unethical or dishonest. I understand I am responsible for all travel, personal or incidental expenses related to the program and otherwise. I understand I am subject to all US local, state and federal law and I agree to abide by them. I am aware that stealing/shoplifting is a serious offense that can and does lead to possible jail time. IENA will provide advice and support if you are arrested, but any and all legal fees are my responsibility. Cancellations: refunds will be coordinated though my sending organization and require a written letter explaining the cancellation and DS-2019. I understand that if I am Terminated (removed from the program), I will lose permission to work and my insurance coverage will be cancelled. I will need to leave the USA immediately. Despite reasonable efforts made by IENA to provide for a positive program experience, IENA cannot guarantee that I will not experience problems or difficulties; these may be temporary or may require me to return to my home country. Such problems may include but are not limited to job loss, firing, SEVIS termination, housing problems or Social Security related problems. IENA will make all reasonable efforts to assist me, but they cannot guarantee a positive outcome.

Initials

13 14 15

WORK 1 I understand I must receive job approval from IENA for each and every job before starting work. 2 I understand that my acceptance to the program is based on having a pre-arranged job. I further understand that when I accept a job with an employer, I agree to do my best, abide by the terms of my contract, to comply with the employer rules and company policies and behave honestly, courteously and responsibly. 3 If I want to take a second job, I must receive permission from IENA before starting the job. I understand I must submit the Employer Data Form, a covering letter and a letter of support from my main employer for approval. Full details and forms are available at www.GoSevis.com. 4 If I have difficulties or problems with my job/employer, I will contact IENA immediately. I will also do my best to work my problems out with my employer. I understand I do not have permission to leave a job until it has been given, in writing, by IENA. 5 I understand I may ONLY work in the USA between the dates in section 3 of the DS-2019. I agree not to work outside those dates. SEVIS and VISA REQUIREMENTS 1 I will go online to www.GoSevis.com to Validate (i.e. provide accurate details of my American residential address, phone number and e-mail address even if temporary) as soon as possible, but no later than 10 days after the start-date in section 3 of my DS-2019. I understand that I may be unable to obtain a Social Security Number unless I have validated. If I fail to do this within 10 days of the start of my DS-2019 (not my arrival date), I understand I may be Terminated from the program. This will end my DS2019 and insurance. 2 I understand the US government requires that SEVIS has my correct details on file and that I must update www.GoSevis.com each and every time that my address or contact details change. If I fail to do this and my details in SEVIS are incorrect, I may be terminated. 3 I understand that my J-1 visa cannot be extended. I declare that I have no intention of staying in the USA after the final date allowed by this program. 4 I understand that I may remain in the US for 30 days after the end of the DS-2019. However, the local US Embassy may require me to return to my home country by the DS-2019 end date. I have discussed this issue with my sending organization. 5 I know of no reason why I may be refused a visa (a: arrest or conviction of a crime; b: born in or travelled to certain Middle Eastern . countries; c: applied to migrate to the US; d: previously experienced US visa/immigration problems; e: overstayed on a previous visit). If I suspect I may have problems, I have disclosed these reasons in writing to my recruiter. If my visa is refused for reasons previously undisclosed, I understand that no refund will be given. I declare that all statements on this application are true; any false declaration may result in forfeiture of my place on the Summer Work Travel Program with no entitlement to any refund or of consequent expenses. I promise to act ethically and responsibly at all times while I am a participant on this program and I understand that any problems caused through my deviation from these and other Sponsor instructions are my own responsibility. Signature: Date:

Updated May 2012