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Work & Travel USA

Work & Travel USA

Application Spring/Summer 2011

Name of CIEE Representative: 



Interviewed by (name): 



Representative Code:

Date (day/month/year):


Departure and Return Dates

Arrival date in U.S. 


Can be no more than five days prior to DS start date.

DS-2019 start date 




Date you want to be eligible to work in the U.S.

DS-2019 end date 



Last day you want to be eligible to work in the U.S. Can be no more than 4 months after DS start date.

Date of departure from U.S. 




Can be no more than 30 days after DS end date and no more than 5 months after arrival date.

Personal Details  

Exactly as they appear on your passport. Please include a copy of your passport’s ID page with your application.

Last Name:

Middle Name: 








First Name:

Gender:            Female           Male 




Date of Birth 


City of Birth:  







Country of Birth:

Country of Citizenship:

Country of Legal Residence:

Passport Number:

Passport Expiration Date 



Contact Information  

Permanent Home Address

Home Mailing Address:

Postal Code: 









Phone Number 

(Country code - City code - Number)






Mobile Number:   






Emergency Contact

Last Name: 








First Name:

Relationship to Participant:


Postal Code: 









Phone Number 

(Country code - City code - Number)






Mobile Number:   




Previous Visas 

Please include copies of previous visas and DS-2019/IAP-66 forms. If you have previously received more than one J-1 Visa, please use an addi-

tional sheet of paper to provide the same information as below for each one.

Have you ever received a J-1 visa to enter the USA?:          Yes 

 No  If yes, how many?:

If yes, please complete the following for each previous J-1 visa:

Name of Program: 







Program Number:

Name of Sponsoring Organization:   










Dates of Previous DS-2019 Form  From 









Other Visa Information

Have you ever applied for a visa to emigrate permanently to the U.S.?          Yes* 


Have you ever been arrested and convicted of a crime? 


        Yes* 


Have you ever been refused a visa by a U.S. Embassy? 


        Yes* 


*If you answered Yes to any of these questions, please contact your CIEE Representative.

Work & Travel USA

Work & Travel USA

Application Spring/Summer 2011

Name of CIEE Representative: 



Interviewed by (name): 



Representative Code:

Date (day/month/year):



Name of Institution 

(e.g. university, polytechnic)




Major Field of Study: 



What is the course length of your major field of study (in years)?: 


How many years of university-level study will you have completed by the time of your departure to the U.S.?: 


Will you be a full-time university-level student at the time you leave to the U.S.?:

Will you be a full-time university-level student when you return to your country of residence?:

Proof of Student Status 

This section must be completed by an official from your educational institution.

If your educational institution will not sign this form you must attach an official letter on university letterhead verifying this same information.

I certify that the named student is registered in our institution as a full time student for the academic year 2011 and is returning to 

full time studies in the semester following the program. 

Name of Student:

Name of the Official signing the Form: 









School Seal/Stamp: 









English Language Ability 

This section must be completed by an English teacher.

Oral English Abilility 


1    Beginner   

2    Intermediate 

    3    Advanced 

Written English   


1    Beginner   

2    Intermediate 

    3    Advanced 

Listening Comprehension   

1    Beginner   

2    Intermediate 

    3    Advanced

Additional comments about the student’s knowledge of English and his/her ability to function in an English-speaking work place:

Name of Teacher 

(Please Print)









Name of Educational Institution 

(Please Print)



Teacher’s Signature: 












How did you find out about Work & Travel USA?

1  




5   Other Website: 

2   CIEE Representative   



6   Placement Agency - Name:

3   Friends/Relatives 




7   Other:

4   School/University

Work & Travel USA

Work & Travel USA

Application Spring/Summer 2011

Name of CIEE Representative: 



Interviewed by (name): 



Representative Code:

Date (day/month/year):

Terms and Conditions / Participant Declaration

This form is important. It includes Terms and Conditions and releases CIEE (Council on International Educational Exchange) from liability. It must be signed by all participants.

I agree that the following terms and conditions are binding on me and my adherence to them is imperative.

Participant’s Name:

Participant’s Signature: 











Participant Responsibilities

1. Each applicant agrees that all the information provided in the appli-

cation is true to the best of his/her knowledge, and acknowledges that 

any false or misleading information may lead to immediate dismissal 

from the Program.

2. The applicant is responsible for considering his/her personal health 

and safety needs when applying for or accepting a place on the 

Program. If the applicant suffers from any health or other condition that 

would create a risk for him/her while abroad, he/she should not apply.

3. The participant is responsible for reading and carefully considering 

all materials made available that relate to safety, health, legal, environ-

mental, political, cultural and religious customs and conditions in the 

U.S.. Each participant must take full responsibility in the event that laws, 

regulations, or customs are broken, regardless of foreknowledge.

4. The participant agrees to pay all fees in accordance with the 

requirements of the CIEE Representative through whom he or she is 

submitting an application.

5. Applicants are responsible for submitting all requested documenta-

tion (including passport) to the CIEE Representative in a timely fashion 

for visa processing. CIEE cannot be held responsible for any additional 

costs incurred (including the cost of rebooking a flight) due to delays 

by participants in submitting documentation or delays by the U.S. 

Embassy in issuing a visa.

6. Each applicant must pay the local visa fee to the U.S. Embassy. Ap-

plicants are responsible for any additional visa fees that might apply at 

the U.S. Embassy or Consulate in the country where they are applying 

for the visa, as well as the government SEVIS fee collected as part of 

the application.

7. All applicants must attend an interview and complete language 

screening in order to participate on the program.

8. Each participant is required to complete a CIEE Orientation.

9. It is the responsibility of the participant to exercise due care once in 

possession of the legal documentation (DS- 2019) and visa. The cost of 

replacing these items must be borne by the participant.

10. The participant must supply CIEE with the name and contact details 

of next of kin, to be contacted in the case of emergency. These details 

must be included on the application form.

11. The participant is responsible for all of his or her acts along with any 

loss or damage resulting therefrom while on the Program. The Partici-

pant agrees to indemnify and hold harmless CIEE and any other party 

that has suffered a loss by reason of the participant’s conduct.


12. All travel before, during and after the Program is at the participant’s 

own risk. Any participant who chooses to operate motorized vehicles is 

responsible for obtaining the necessary license, permission and insur-

ance and does so at his/her own risk.

13. If, during the course of the program the participant encounters any 

difficulties with safety, health, the job, housing, including charges or 

fees for housing, sanitary conditions, overcrowding, etc. or any other 

problem, the participant must notify CIEE as soon as possible by phon-

ing CIEE at 1-888-268-6245, 24 hours a day, 7 days a week.

14. Participants on Work & Travel USA are required to comply with all 

U.S. Government visa and immigration requirements including the SE-

VIS tracking as follows: a) notification of arrival at U.S. Employer to CIEE 

within 20 days of DS-2019 program start date. b) notification to CIEE of 

any change in U.S. home address within 10 days of change.

Employment or Job Related Conditions

15. CIEE cannot accept applications from participants intending to 

work in the U.S. as au pairs, child carers, teachers, teaching assistants, 

camp counselors, in private households, as ship or aircraft crew mem-

bers, or as medical staff having patient contact. From time to time the 

list of prohibited jobs is updated and listed on our website.

16. Under no circumstances are job positions guaranteed. Even in the 

case when an employer represents that a job is being held, this does 

not constitute a binding contract that the job will be available when 

the participant arrives. The employer’s commitment is one of good 

faith only. In addition, if the participant does not have sufficient English 

skills and/or does not arrive on time and/or has misrepresented any 

statement in the application, there is an extremely high likelihood the 

position will not be available to the participant. In addition, if the par-

ticipant does not meet the contractual obligations with the employer 

or with CIEE, the sponsorship agreement with CIEE may, at CIEE’s sole 

discretion, be terminated.

17. Participants must work for the employer listed on their Employ-

ment Offer Agreement Form. If, for any reason, a change of employer 

becomes necessary, participants must contact CIEE and get approval 

BEFORE changing jobs.

18. Participants on the Work & Travel USA are required to maintain com-

munication with their employer prior to arrival, notify them in advance 

of their arrival and departure dates, and advise them of any changes to 

their travel itinerary due to visa delays or any unforeseen circumstances.

19. Due to weather conditions, or other factors beyond CIEE’s control, 

some jobs have uncertain start dates and hours of work. The participant 

must be able to support himself/herself in the U.S. until he/she gets his/

her first paycheck, and in the event of reduced working hours, and must 

have at least $475 with themselves upon arrival in the U.S.

20. CIEE/Representative are not responsible for the participant’s 

expenses incurred if for any reason the participant has not started 

work by the agreed date due to weather conditions at his/her place 

of employment or for any other reason not under the direct control of 


21. Once a participant accepts a position with a CIEE-sourced employer 

he/she agrees to stay at that place of employment for the duration of 

the program. If he/she wishes to leave a position after he/she starts 

work or to decline to start work after accepting a position, he/she must 

notify CIEE in writing and he/she must obtain its written permission 

to do so. Except in extraordinary circumstances, such permission will 

not be granted. If he/she does not receive prior written approval to 

change jobs, and if he/she leaves this employment without the prior 

written approval of CIEE, CIEE reserves the right to revoke his/her legal 

sponsorship which will result in the termination of his/her program and 

his/her legal right to remain in the U.S..

22. If a CIEE-sourced job position is no longer available, through no 

fault of the participant’s own, after a signed EOAF has been issued to 

participant, or if for any reason CIEE deems it necessary to relocate a 

participant from a CIEE-sourced job either before the job commences or 

at any time during the job period, CIEE will assist the participant in find-

ing another position but CIEE makes no guarantee with respect to being 

able to do so. Nor does CIEE make any representation that it will be 

able to find work for the participants in the same geographical area or of 

the same type of work or pay as the original CIEE-sourced job.

23. In case of change of job or of premature termination of job, or if 

the employment is terminated before the end of the program for any 

reason, or if the participant decides to return home early, no fees will 

be refunded.

24. If a participant is fired from his or her job for violation of employer 

policies, including their failure of a company required drug test at the 

commencement of or anytime during employment, he or she will be 

withdrawn from the program with no refund of program or CIEE Job 

Service fees.

25. If the participant’s original job ends before the legal working dates 

listed on the DS 2019 (program end date) for any reason, it is the 

participant’s responsibility to inform CIEE’s U.S. office and get approval 

for any new job.

Contractual Terms

26. This English language version of the Contract is the binding contract 

between the participant and CIEE.

27. CIEE makes no presentation or warranty of any kind, expressed or 

implied, as to the suitability of the Program for any participant and CIEE 

disclaims all such warranties to the full extent of the law.

28. The conduct of the Work &Travel USA Program is subject to U.S. 

government approval and may change without notice.

29. The participant understands that perceived or actual epidemics (such 

as, but not limited to, SARS or bird flu) can seriously delay, disrupt, inter-

rupt or cause the cancellation of entire programs. The participant agrees 

to assume all risks and losses (including financial) which result from any 

such occurrence.

30. CIEE does not own or operate any entity which is to or does provide 

goods or services for the program including, for example, arrangements 

for or ownership or control over houses, apartments or other lodging 

facilities, airline, vessel, bus or other transportation companies, food 

service or entertainment providers, etc. All such persons and entities are 

independent contractors. As a result, CIEE is not liable for any negligent 

or willful act or failure to act of any such person or entity, or of any third 

party. Without limitation, CIEE is not responsible for any injury, loss, 

or damage to person or property, death, delay or inconvenience in 

connection with the provision of any goods or services occasioned by 

or resulting from, but not limited to, acts of God, force majeure, acts of 

war or civil unrest, insurrection or revolt, strikes or other labor activities, 

criminal or terrorist activities of any kind, overbooking or downgrading of 

accommodations, structural or other defective conditions houses, apart-

ments or other lodging facilities (or in any heating, plumbing, electrical 

or structural problem therein), mechanical or other failure of airplanes 

or other means of transportation or for any failure of any transportation 

mechanism to arrive or depart timely, dangers associated with domestic 

or wild animals, sanitation problems, food poisoning disease, lack of, 

access to or quality of medical care, difficulty in evacuation in case of 

medical or other emergency, or for any other cause beyond the direct 

control of CIEE.

31. The participant agrees that any dispute concerning, relating, or 

referring to the Employment Offer Agreement Form, to  the Work & 

Travel USA Application, to any other literature concerning the program, 

or the program itself shall be resolved exclusively by binding arbitration 

in Maine, according to then existing rules of the American Arbitration 

Association. Such proceedings will be governed by substantive Maine 


32. CIEE reserves the right to provide you with information on tax and 

related services. 

CIEE Program-Related Conditions

33. CIEE reserves the right to refuse sponsorship of any applicant that 

CIEE deems does not meet the Program eligibility requirements or 

any applicant that CIEE does not deem appropriate to accept in the 

general interests of the Program. In  the event that CIEE refuses an 

applicant and acceptance on the Program, any refund will be made via 

the CIEE Representative through whom the original application was 


34. Participation on the Program begins when the participant legally 

enters the U.S. and terminates on the day of departure from the U.S. 

(within the legal Program dates). Participation on the Program will end 

a maximum of 5 months from arrival in the U.S. Participants can arrive 5 

days prior to their DS Program start date and remain in the U.S. up to 

30 days beyond their DS Program end dates, as long as their total stay 

in the U.S. does not exceed 5 months. Participants must return to their 

home country in time for the start of their university classes.

35. CIEE may issue a DS-2019 form if a participant meets the Work & 

Travel USA Program requirements, but cannot guarantee that the U.S. 

Embassy or Consulate in a participant’s country of residence will issue 

a J1 visa.

36. Once a participant has commenced his/her travel to the U.S. CIEE 

cannot amend the program dates as listed on the DS-2019for any 

reason. It is the participant’s responsibility to check prior to travel that 

the dates are correct.

37. Individuals who have recently held a J-1 visa for the U.S. may have 

to remain in their home country for a minimum of 90 days before CIEE 

can issue a DS-2019 for Work &Travel USA. Please contact your local 

CIEE Representative and local U.S. Embassy for details.

38. Insurance is provided for the dates confirmed by CIEE, by CIEE’s 

insurance provider, as a mandatory part of the CIEE program for each 

applicant. It is the responsibility of each participant to purchase further 

insurance should they extend their period abroad for any reason. CIEE 

cannot be held responsible for any insurance claim in the event that a 

participant has failed to secure adequate insurance.

39. Under the U.S. government’s Health Insurance Portability and 

Accountability Act (HIPAA), CIEE is restricted in its access to certain 

medical information or records in the event that a participant has an 

accident in the U.S. In order for CIEE to assist participants to the fullest 

extent possible with any insurance-related issues, CIEE will need to 

have a signed Privacy and Confidentiality Release Form from the par-

ticipant. This form is optional and the participant can choose whether 

or not CIEE is granted access to this information. This release form and 

additional information about the HIPAA requirements are included as 

part of the Work & Travel application pack. If you did not receive this 

information or release form please contact your CIEE representative.

40. CIEE reserves the right to dismiss from the Program any participant 

who is deemed by CIEE to be a danger to him/herself for others or 

whose conduct is deemed to be detrimental to the Program. In the 

event of such a dismissal, CIEE shall not beheld responsible for any 

airfare, charges or any other expense incurred by the participant, and 

shall not be required to return any fees paid by the participant.

41. Once the participant has departed for the U.S., there will be no 

refund should the participant leave the Program. There will also be no 

refund should CIEE withdraw sponsorship.

42. CIEE/Representative do not provide housing. If an employer does 

offer housing it is usually on a first-come first-served basis. Whether the 

participant arranges housing independently or through the employer 

the participant will be required to sign a lease and pay a deposit, which 

usually amounts to the first and last month’s rent and may include an 

additional security deposit.

43. CIEE may provide the participant’s contact information to third 

parties who provide useful services to exchange program participants. 

Third parties receiving this information will be required to provide the 

participant with the opportunity to opt out after the first contact.

I confirm that the statements contained in this application form are accurate to the best of my knowledge, and I understand and accept the Standard Terms and Conditions.

For further reference please make a copy of the above Terms & Conditions.

Work & Travel USA

Work & Travel USA

Interview Form Spring/Summer 2011

Name of CIEE Representative: 



Interviewed by (name): 



Representative Code:

Date (day/month/year):

Applicant Details

Last Name:

First Name: 









Middle Name:

Privacy, HIPAA, and Confidentiality Release Form

By completing this form, you give consent to CIEE, your parents or guardian, your physicians and/or other medical providers to 

discuss your medical and/or insurance issues with CIEE. You also consent to CIEE utilizing any such material in and as necessary in 

treating any medical condition which may arise. You also consent that CIEE may notify your emergency contact listed in this applica-

tion of any situation that we deem to be an emergency. In addition, you consent that CIEE may notify the official CIEE designated  

agency from whom you purchased this program of any situation that we deem to be an emergency.

This authorization is valid for two years from the date signed.

Under no circumstances can CIEE release medical information from your physician or provider of service to you or anyone. Your 

medical information has been disclosed to us from your physician or provider of service and we are prohibited by federal law from 

further disclosure. Please contact your physician or provider of service for your medical information.

I give CIEE permission to release any or all of the following information in and as appropriate in the event of a medical condition. 

(Please initial and check each box.)



All financial and claim information related to medical bills or Claimant’s Statement and Authorization.



Provide name, date of service, total charge, total paid, and date of payment.



Insurance ID number and/or social security number.

Print Patient Name:

Signature of the Patient, Adult Parent, or Guardian:




Interview Details  

To be filled out by a CIEE Representative based on in-person interview.

Have you ever been to the U.S. before? 


Yes        No

If yes, for what purpose?:

What are the benefits to you of spending a summer living and working in the U.S.?:

Do you already have a job in the U.S.? 


Yes        No

If no, what type of work do you hope to find?:

Do you have friends or relatives currently living in the U.S.? 

   Yes        No

Do you plan to travel in the U.S. during your stay? 

  Yes        No

Return from the U.S.

What do you plan to do upon your return from the U.S.?  

            Continue studying

  Other (please specify):

Would you consider doing an internship in the U.S. in the future?            Yes       No

Interviewed by

Full name: 





















Document Outline

  • WAT 2011 Application
  • Interview form 2011

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