Place this completed checklist on top of the application you send to Cultural Vistas.

Transcription

1 Place this completed checklist on top of the application you send to Cultural Vistas. Expedited Application Review: 5 business-day review (Additional Cost) participant and host company information Expedited Site Visit: 5 business-day review (Additional Cost) Mr. Ms. Dr. Participant Name Citizenship Host Company Name Student: Foreign national currently enrolled in and pursuing studies at a degree- or certificate-granting post-secondary academic institution outside the United States Non-Student: All applicants not currently enrolled in a degree- or certificate-granting post-secondary academic institution are considered non-students application checklist Signed, completed Exchange Visitor Application form Photocopy of a valid passport photo page and name/issuance page (name and birth date must be clear and legible) Essay Resume Proof of English language ability dated within the past 3 years (certificate, exam, interview document, or school course verification). If you do not possess such documentation, an interview will be scheduled with Cultural Vistas Copies of any previous DS-2019/DS-7002 forms if you have already participated in a J-1 visa program Statement of Health Insurance Coverage Documents should be on official school or company letterhead, include a signature of the author where applicable, and confirm the dates of attendance or employment. If you are a student, send: Letter from school confirming full-time student status Copy of your transcript If you are a recent graduate, please send: A copy of the certificate or diploma Copy of your transcript or one letter of reference from a professor or recent employer If you are a non-student, send: Copy of most recent certificate or diploma, and Employment verification letters confirming you have 1 year related full-time work experience (ex. 2 jobs within a 12 month period requires 2 reference letters) OR Employment verification letters confirming you have 5 years related full-time work experience (1 letter per position held within past 5 years; ex. 3 jobs within 5 years = 3 reference letters) Administration fee (paid by: Participant Host Company Other)

2 personal information First Name Last Name Other or Middle Name Birth Date Gender male female Status student non-student Marital Status single married Passport Number of Birth of Citizenship Expiration Date of Birth of Permanent Legal Residence contact information Current Address Line 1 Address Line 2 State Zip Code Address Valid Until Permanent Address Line 1 Address Line 2 State Zip Code Address Valid Until Home Phone Mobile Phone Work Phone Other Phone Personal Work

3 emergency contact Mr. Ms. Dr. First Name Last Name Relationship Address Line 1 Address Line 2 State Zip Code Phone position information How did you learn of the position with your host company? Start Date Prospective Host Company Name Mr. Ms. Dr. Name of Contact Person Title Phone knowledge of English language Is English your native language? Yes No If no, Cultural Vistas will require documentation to verify your English language skills. Please rate your knowledge of the English language: Speaking Poor Fair Good Excellent Reading Poor Fair Good Excellent Writing Poor Fair Good Excellent

4 visa information At which U.S. Embassy/Consulate will you apply for your J-1 visa? Have you previously visited the United States on a non-tourist visa? Yes No If yes, answer the following: Date of Entry Date of Departure Type of Visa Purpose of Visit Please include a copy of visa documents with the application. Are you currently in or have you in the last 12 months come to the United States on a tourist visa? Yes No If yes, answer the following: Date of Entry Date of Departure Purpose of Visit Have you ever been refused a visa to the United States? Yes No If yes, answer the following: Type of Visa Date of Refusal Reason for Refusal If you have ever overstayed the approved time on a visa or tourist waiver status during a trip to the United States, please explain: financial information Will you receive funds from the U.S. government, from a foreign government, or any other organization during your training in the United States (besides the host company)? If yes, please provide the following information. Institution Name Amount: $ Personal Funds: $ (This is how much of your own money you expect to spend to support yourself during the program)

5 education Please list the school in which you are currently enrolled, or from which you most recently graduated. Do not list primary or secondary schools. You may then add new records for additional schools. School Name Degree/Certificate Major School Name Degree/Certificate Major School Name Degree/Certificate Major School Name Degree/Certificate Major

6 employment List your current employer or activity first. Your most recent work experience(s) must be within the past six months. You may then add new records for previous work experiences. Please also include your past internship experience if applicable and all U.S. work or internship experience. You will have the opportunity to add a CV to supplement this information in the application stage. Company Name Job Title Company Name Job Title Company Name Job Title Company Name Job Title

7 essay Please respond in complete sentences and in English. Each response should be 250 words or less. (If you have participated in a J-1 visa internship or training previously please explain what new skills or knowledge you expect to gain from the experience that differs from your previous internship or training.) What specific skills do you hope to learn in the United States that you would not learn in your home country or another foreign country? How will this program benefit you in terms of career development and international cultural understanding?

8 dependent information Please indicate below if you plan to request authorization for your dependents to accompany you to the United States during your training program. Dependents are defined as a legally married spouse and/or children less than 21 years of age. Marriage certificate and/or birth certificate copies are required. Dependents will accompany me to the United States Yes No First Name Other or Middle Name Last Name Date of Birth Relationship spouse child Gender male female of Birth of Citizenship of Birth of Permanent Legal Residence This Dependent will arrive with me later Expected Arrival Date First Name Other or Middle Name Last Name Date of Birth Relationship spouse child Gender male female of Birth of Citizenship of Birth of Permanent Legal Residence This Dependent will arrive with me later Expected Arrival Date

9 First Name Other or Middle Name Last Name Date of Birth Relationship spouse child Gender male female of Birth of Citizenship of Birth of Permanent Legal Residence This Dependent will arrive with me later Expected Arrival Date First Name Other or Middle Name Last Name Date of Birth Relationship spouse child Gender male female of Birth of Citizenship of Birth of Permanent Legal Residence This Dependent will arrive with me later Expected Arrival Date

10 dependent health insurance U.S. Federal Regulations state that all accompanying dependents that enter the United States under the sponsorship of Cultural Vistas must be covered by health and accident insurance for the entire duration of the training program. The minimum requirements for insurance are: 1. medical benefits of at least $50,000 per accident or illness; 2. repatriation of remains in the amount of $7,500; 3. expenses associated with medical evacuation from the United States to the participant s home country in the amount of $10,000; and 4. a deductible not to exceed $500 per accident or illness. The insurance policy must also be underwritten by an insurance corporation having an A.M. Best rating of A- or above, an Insurance Solvency International, Ltd. (ISI) rating of A-i or above, a Standard & Poor s Claims-paying Ability rating of A- or above, or a Weiss Research, Inc. rating of B+ or above OR be backed by the full faith and credit of the government of the exchange visitor s home country. For full details please reference the Code of Federal Regulations (22 CFR Part 62). Please indicate your insurance preference below for J-2 dependents. I will provide health insurance for my dependents that meets or exceeds the requirements of 22 CFR Part 62. I am aware that if I willfully fail to carry health insurance for my dependents, or if I misrepresent my dependents insurance coverage, then Cultural Vistas must terminate my program. I hereby certify this coverage will be in effect for the entire duration of my program in the United States. If this policy is not valid through the entire duration of the training program, I certify that it can and will be renewed. Enter Insurance policy details: Policy Number Carrier Start Date I will provide health insurance for my dependents that meets the above requirements except for medical evacuation and repatriation. I would like to purchase Medical Evacuation or Repatriation coverage at a cost of $7 per month which covers all my dependents. Enter Insurance policy details: Policy Number Start Date Carrier I will enroll my dependents in Cultural Vistas insurance at a cost of $380 per month which covers all my dependents. Payment for dependent insurance coverage must be made in full for entire coverage period and be received by Cultural Vistas prior to dependent document issuance.

11 Exchange Visitor Obligations and Responsibilities I recognize that Cultural Vistas is my legal sponsor while I am in the United States as a J-1 participant. I acknowledge that Cultural Vistas must approve in advance any changes in the program and that I am responsible for reporting to Cultural Vistas, in a timely manner, any changes in program location; dates; salary; or any substantial changes in the content of my program. I understand that I am not authorized to leave my Cultural Vistas-sponsored training/internship program, nor will I seek a training/internship position with any other U.S. company/firm/organization while I am sponsored by Cultural Vistas. In the event of a breach in the internship program on the part of the host organization, I will contact Cultural Vistas immediately to seek assistance. If I voluntarily leave my host company, I agree to leave the United States within 10 days and will provide a copy of my airline ticket out of the United States, and an explanation of my departure. I understand that if I leave my training/internship program and do not leave the US by the date agreed upon with Cultural Vistas my program will be cancelled and I will be in the United States illegally. If I change host organizations without permission from Cultural Vistas, my program will be terminated and I will be required to leave the United States. I understand that the intent of the J-1 Exchange Visitor Visa program is to allow me to enhance my skills and gain exposure to U.S. culture and business practices that will be beneficial upon my return home. Use of the program for ordinary employment or work purposes is strictly prohibited. I hereby pledge that I will not seek any changes in visa status during my Cultural Vistas-sponsored J-1 visa program. Therefore, it is my intention to leave the United States at the end of my program. I agree to provide Cultural Vistas with my date of entry to the United States, an established local U.S. address and phone number within 10 days of arrival, as well as all Cultural Vistas forms and evaluations. During my stay in the United States, I will notify Cultural Vistas of any changes in my current address within 10 days of the change. U.S. government regulations stipulate that failure to do so will result in the automatic cancellation of my J-1 visa. I understand that my Certificate of Eligibility (Form DS-2019) will reflect the dates of my training/internship program. I realize that if I complete my program I will have 30 days beyond the end date given on the Certificate of Eligibility to conclude my affairs and travel in the United States, and that I will then be expected to exit the United States. I certify that I will comply with laws, regulations and/or instructions of appropriate government agencies in the United States. Failure to do so may result in cancellation of my program by Cultural Vistas. I understand the U.S. consulate or embassy will make the final determination whether to issue the J-1 Exchange Visitor visa. Cultural Vistas has no power to influence either a positive or negative decision on my behalf. Cultural Vistas reserves the right to withdraw sponsorship at any time. I understand that although my Cultural Vistas health insurance plan is compliant with the Department of State regulations, it is not intended to provide comprehensive health care coverage and does not meet Minimum Creditable Coverage standards required by state law in Massachusetts. I agree that I am responsible for any penalties incurred as a result of my non-compliance with the Massachusetts state standards. For more information call the Connector at MA-ENROLL or visit the Connector website ( If you have questions about this, you may contact the Division of Insurance by calling (617) or visiting its website at I take part in a training/internship program in the United States at my own risk and of my own volition. Cultural Vistas cannot be held liable under American or my home country s law for any damage or injury; in particular injury to persons or damage to property, suffered by or caused by myself, during the course of the program.

12 I understand that Cultural Vistas undertakes a variety of activities to adequately prepare its participants, including, but not limited to, information on health and safety issues, insurance issues, housing and accommodation, visa and residency requirements, political and cultural conditions, roles and responsibilities of partners and host organizations, and laws specific to the United States. Beyond this preparation, a range of issues related to a participant s experience is beyond the control of Cultural Vistas. Cultural Vistas cannot: Guarantee or assure the safety of participants or eliminate all risks from the participant s environment while in the United States; Prevent participants from engaging in illegal, dangerous or unwise activities; Provide or pay for legal representation for participants; Assume responsibility for the actions of persons not employed or otherwise engaged by Cultural Vistas, for events that are not part of the program, or that are beyond the control of Cultural Vistas and its subcontractors, or for situations that may arise due to the failure of a participant to disclose pertinent information. I acknowledge and accept the limitations to the liability of the administering organization as listed above. I hereby release Cultural Vistas, Inc., their officers, directors, agents, representatives, successors and assignees from any claims and causes of action, heretofore or hereafter arising, known or unknown, by reason of violence or natural disasters affecting me or my property while participating in this program. The Parties [person or entity named in this application] agree that arbitration is the required and exclusive forum for the resolution of any and all disputes between them. Read the entire arbitration agreement on our Web site at or request a copy be sent to you by contacting us at I attest that I have read and understand the information given above and certify that all statements made by me in this application are true and correct. Signature Date Full Name