America Work Visa, Inc

J-1 Application Form

If the worker does not have an email, please enter the recruiter's email or email of the person who completed this form.

Work and Travel Start Date:		(Day) (Month)
Work and Travel End Date:		(Day) (Month)
Intership Start Date:		(Day) (Month)
Intership End Date:		(Day) (Month)

This form is completed by:
Recruiter/Company Name *		(Please use exactly the same information here if you are filling out more than one application)
Country *
Referred by
Job Position *
Nationality
Passport Number
Passport Expiration Date		(MM/DD/YYYY)

Personal Information
Name(as shown on passport)	Last Name * Middle Name(if you have) First Name *
	Social Security No, if available
	Date Of Birth *	(MM/DD/YYYY)	Gender *
	Marital Status *		E-mail *
	Cell Phone		Home Phone *
Current Address	Street *		City *
	State/Province		Zip Code
	Country *
Permanent Address(if different from current)	Street		City
	State/Province		Zip Code
	Country
In case of emergency	Contact Name		Phone

Education
	Course of Study:		Name of School
	Expected Completion Date:	(MM/YYYY)

Work Experience
	Company Name		Job Title
	From	(MM/YYYY)	To	(Present or MM/YYYY)
	Job Description


	English Level *		Physical Ability

Have you ever applied for US Visa? If yes, what type of Visa?
Have you ever participated on a J-1 Work & Travel Program?
If yes, how Many Times?