J-1 Summer Work & Travel Program Registration Form
Instructions: Before you start this application, ensure to the have the required documents listed on the J-1 Summer Work and Travel Program website.
Personal Details
Name
*
First Name
Last Name
Gender
*
Female
Male
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Country of Residence
Birth City
*
Birth Country
*
Resident of
*
Citizen of
*
Program Eligibility
I am a full-time student at an accredited university or other state recognized institution of post-secondary education. The degree/diploma course on which you are registered must be at least 2 years in duration. You must have completed at least one semester of study. Students on post-graduate courses which are less than two years can also be accepted (e.g. masters courses). "Gap year" students or high school graduates are not eligible. I am also between the ages of 18-30 years old
*
Yes, I agree
College/University:
*
College/University Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
College/University Phone:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Year of Study: (Students must enter):
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Graduation Date (Students must enter):
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Major (Students must enter):
*
Are you taking at least 12 credits this semester? (Students must enter):
*
Yes
No
Available Start Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
When does school breaks start?
Emergency Contact
Name
*
First Name
Last Name
Relationship
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Health History
Do you have an illness that may impair your ability to work?
*
Are you taking any medications?
*
Yes
No
If yes, state:
Travel History
Do you have travel history within the past 5 years?
*
Yes
No
Do you have a US Visa?
*
Yes
No
Visa Control Number
*
Visa issue date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Visa expiry date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you ever been denied entry, or your visa revoked?
*
Yes
No
If yes, please state why?
Have you ever been arrested or have any cases before the court?
*
Yes
No
J-1 Program History
Membership Fee Receipt
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Program Fee Deposit Receipt
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Digital Photo
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Passport Bio Page
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
CV/Resume
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Proof of Status School Status
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Signed Agency J-1 Summer Work and Travel Program Terms and Conditions
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Signature
*
Continue
Continue
Should be Empty: