WORK AND TRAVEL ENROLLMENT FORM

PERSONAL INFORMATION

Family Name: __________________________Given Name:_________________________________ Gender: Male Female

Date of birth: (MM/DD/YYYY) _______________ City and Country of birth: ______________________Country of citizenship/residence:
_________________ National identification: ___________________________Passport Number: _______________________________
Home Address: _______________________________Postal Code: _____________ City and Country:____________________________
Home Phone:_____________________ Cellphone: ________________E-mail: _________________ Skype user name (Mandatory):
________________________ Instagram: ________________Facebook: ________________________T-shirt size:__________________
How did you learn about OVLEX? /Referred by (Optional):_______________________________________________________________
EMERGENCY CONTACT INFORMATION

Family Name: ___________________________________________ Given Name: ____________________________________________

Relationship: (Mother/Father/ Brother, etc…) ______________________ Address: ___________________________________________
Cellphone: ____________________________ E-mail: ___________________________________________________________________
STUDIES INFORMATION
Current University Name: ______________________________Address:________________________________City:________________
Country:_________________ University Career:______________________________ Numbers of years completed:_________________
Current semester: ___________________University start date: ________ / _______ Expected graduation date: _________ / _______
Month Year Month Year

VISA PROGRAM DATES: Please provide tentative program dates for your Work and Travel Program:

University Summer Break Dates: Begin: _ _____End: _______________________

Month Day Year Month Day Year

I certify that I am a University/Institute student enrolled full-time in at least the second semester of my major and pursuing studies
at a post-secondary accredited academic institution. I intend to visit the USA on the J-1 Work and Travel program during my summer
break period (Visa Program Dates listed above) and will return to my home country to continue my full-time studies following my
visit to the USA. I agree to provide my agency and my SPONSOR with documentation of my full-time student status with an official
university letter signed, stamped and dated by my university as verification and proof of my eligibility for this program.

Have you ever studied another career/major? Yes No

If yes / did you finish it? Yes No From: ______ / _______ To: _______ / _______
Month Year Month Year

TRAVEL BACKGROUND:
Have you ever applied for a visa to the United States? Yes No
If yes, was this visa approved? Yes No, Which type of visa was this? ____________________________________________

Have you ever visited the United States before? Yes No

If you visited US as a J1, please provide the following information:

How many times have applied to the Work and Travel Program before? ___________________________________________________

Agency (s) name (s) in Ecuador:___________________________ Sponsor(s) name (s) in USA:__________________________________

Employer (s) name (s) and Job Type:________________________________________________________________________________

Print Name ______________________________________Signature: ____________________________________Date: _____________

SKILLS INFORMATION:

Evaluate your performance regarding the following skills. Please mark with an “X”

Beginner Intermediate Advanced

English - Speaking
English - Written
Swimming
Cooking
Housekeeping
Customer service
Cash Registering
Heavy Lifting

Why would you make a good employee for a USA company?______________________________________________________________

Provide the following answers regarding yourself:

Have you ever been convicted of a crime? Yes No Do you have beard or goatee? Yes No
Will you submit to a drug test? Yes No Do you have visible tattoos Yes No
Will y you submit to a health test? Yes No Do you have nose or facial Yes No
piercings
Will you pay for a certification fee? Ex. Lifeguard Yes No Do you have colorful hair? Yes No

HEALTH INFORMATION

Do you have any medical condition that may limit the type of work you can take for this program?

Yes No

If yes, please explain ____________________________________________________________________________________________

Do you have any pre-existing medical conditions? (Including surgeries, hospitalization, mental illness, or psychiatric care)

Yes No

If yes, please explain _____________________________________________________________________________________________

Do you take any regular medication?

Yes No

If yes, please explain _____________________________________________________________________________________________

List any allergies or special dietary restrictions you have:

______________________________________________________________________________________________________________
______________________________________________________________________________________________________________

List any illnesses or physical restrictions you have:

______________________________________________________________________________________________________________
______________________________________________________________________________________________________________

We are about to get started! Please provide the name of your preferred Work and Travel location to your coordinator.

Work and Travel Enrollment Agreement

By typing my name and signing below, I certify all information is true and correct to the best of my knowledge. I understand that my
agency OVLEX and my SPONSOR may deny my application due to the information provided. I authorize both to distribute this information
provided on this Enrollment Form to employers and representatives as deemed necessary for my program. By signing below, I agree to
participate in the Work and Travel program and willingly accept all terms and conditions set forth by my agency OVLEX, my SPONSOR,
and my designated host US employer.

Print Name ______________________________________Signature: ____________________________________Date: _____________