12-Month U.S.A.

Intern Work Programme

Participant Application
Dear Program Applicant, Thank you for your interest in participating on the 12-Month U.S.A. Intern Work Programme through USIT and CIEE: Council on International Educational Exchange. CIEE has been authorized by the U.S. Department of State to sponsor candidates on this 12-month program as part of the J-1 Exchange Visitor Visa. To verify basic program eligibility and ensure that we have the correct information on file for each participant, you will be required to complete the following application in its entirety and return it to your USIT representative in Ireland. In order to allow sufficient time for application processing and for the mandatory visa interview at the U.S. Embassy in Dublin, we recommend that you submit your complete application to USIT at least six weeks prior to your intended departure to the U.S. Please keep in mind that the program is open to: Irish citizens of at least 18 years of age travelling without dependents to the U.S. Participants who plan to secure an internship work placement in a position related to their current studies Post-secondary college/university students (enrolled and participating), or recent graduates who have graduated from a post-secondary college/university within the 32 Counties of Ireland no more than 12 months prior to their program start date Vocational students whose study is part of a structured program leading to a degree or other credential equivalent to Level VI of the Irish Higher Education System To help you in completing the 12-Month U.S.A. Intern Work Programme Application, we have included a checklist on the following page and ask that you use this as a guide to completing the application. For further assistance you may contact USIT Ireland at 01.602.1667. Thank you again for you interest in this exciting new program and we look forward to welcoming you to the United States in the near future. Sincerely, CIEE

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CIEE 12-Month U.S.A. IWP Last updated: 2010.10.01

12-Month U.S.A. Intern Work Programme

Participant Application
12-Month U.S. Intern Work Program Checklist
Applicant Information Signed Financial Security Statement (Page 5 of this application) Proof of Student Status and Academic Endorsement or Copy of Qualification (with graduation date within 12 months of intended program start) Program Information Page Applicant Declaration and Signature Copy of valid passport

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CIEE 12-Month U.S.A. IWP Last updated: 2010.10.01

12-Month U.S.A. Intern Work Programme

Participant Application
Applicant Information
Departure and Return Dates (Please note that these dates should not be changed after your application has been submitted.) Date of departure to U.S. and DS-2019 (Official Work Papers) start date (mm/dd/yy):
This should be exactly 12 months after your departure date

Date of return to home country and DS-2019 (Official Work Papers) end date (mm/dd/yy):

Personal Details (Please fill these in as they appear on your passport.) Last name: First name: Gender: Female Male Country of birth: Date of birth (mm/dd/yy): Place of birth: Country of citizenship: Country of legal permanent residence: Passport number: Contact Information Email (mandatory): Current street address: Postal code: City: Country: Home telephone (countrycode/citycode/number): Mobile/cellular telephone (countrycode/citycode/number): Permanent address ( Check if same as above): Street address: Postal code: City: Country: Passport expiration date (mm/dd/yy): Middle name:

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CIEE 12-Month U.S.A. IWP Last updated: 2010.10.01

12-Month U.S.A. Intern Work Programme

Participant Application
Emergency Contact in Ireland Last name: First name: Relationship to participant: Email: Address: City: Zip code: Home telephone (countrycode/citycode/number): Mobile/cellular telephone (countrycode/citycode/number): Previous Visas (If you need more space, please attach a separate sheet of paper) Have you ever received a J-1 Visa to enter the U.S.? 1) Type of program: Summer work/travel Au Pair or EduCare Camp Counselor Trainee Intern Other, specify: Yes No If yes, how many? State:

Organization (employer): J-1 Sponsor: City: State: From: Organization (employer): J-1 Sponsor: City: State: From: To: To:

Dates of previous DS-2019 or IAP-66 (mm/dd/yy): 2) Type of program: Summer work/travel Au Pair or EduCare Camp Counselor Trainee Intern Other, specify:

Dates of previous DS-2019 or IAP-66 (mm/dd/yy):

Other Visa Information (If you answered yes to any of these questions, please submit explanatory documentation with this application) Have you ever been denied entry into the United States? Have you ever applied for a visa to immigrate permanently to the U.S.? Have you ever been arrested and/or convicted of a crime in your home country? Have you ever been arrested and/or convicted in the U.S.? Have you ever been refused a visa by a U.S. Embassy or Consulate? Yes Yes Yes Yes Yes No No No No No

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CIEE 12-Month U.S.A. IWP Last updated: 2010.10.01

12-Month U.S.A. Intern Work Programme

Participant Application
Financial Security Statement
Applicantsmustprovideproofofsufficientfinancialresourcestosupportthemselvesthroughouttheirentirestayinthe U.S.Thetotalamountrequiredis$750multipliedbythetotalnumberofmonthstobespentintheU.S. Tobegintheprogram,participantswillberequiredtohaveatleasttwomonthsoffundingattheirdisposal.Thereafter, participantswillneedtomaintainthesameleveloffundingeitherthroughwagespaidbytheiremployerorthrough additionalpersonalfunding.Iftheinternshipisunpaidordoesnotmeetthe$750permonthrequirement,participants willberequiredtoprovideadditionalproofoffunding,whichmayincludealetteroffinancialsupportfromaguarantor inIrelandoracopyofabankstatement. Furthermore,participantsthatcannotfindaninternshipwithintwomonthsoftheirprogramstartdatewillberequired byCIEEtoshowanadditionaltwomonthsoffunds($750permonth)intheformofaguarantorletterorcopyofa currentbankstatement.Proofoffundswillberequestedeverytwomonthswhileyoucontinueyoursearchforan internship.Youshouldplantohavesufficientfundsonhandintheeventthatyouhavedifficultyfindinganapproved internshipintheUnitedStates. I confirm that I will have at least $1,500 at my disposal to begin the program and will be able to show proof of these funds to USIT and/or a U.S. immigration officer upon request. I further confirm that, if my internship does not provide me with at least $750 per month in wages or I have not located a CIEE-approved internship within two months of my program start date, I will provide CIEE with additional proof of funds to meet the requirement of $750 per month of stay in the U.S. Signature: Date:

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CIEE 12-Month U.S.A. IWP Last updated: 2010.10.01

12-Month U.S.A. Intern Work Programme

Participant Application
Proof of Academic Status and Academic Endorsement
12-Month U.S.A. Intern Work Programme Enrolled Students Students enrolled in a recognized third-level institution (studying at least Level 6 of the Irish Higher Educational System) must have this section completed by an Academic Advisor, Placement Officer, Counselor, or Department Head from your academic institution. Name of Academic Institution: Name of Academic Advisor: Title: Telephone: Website: I certify that the U.S., is currently enrolled at my institution. Are you currently enrolled full-time in your academic program? Years of study completed at the time of departure: Anticipated graduation date (mm/dd/yy): Major/field of study: Name of qualification: Signature: Academic emblem or seal: Date: , the applicant for an internship program in Yes No Email:

Recent Graduates If you have already graduated and received your qualification from a third-level academic institution within the 32 Counties of Ireland and will begin your 12-Month U.S.A. IWP within 12 months of graduation, please provide the following information. Name of Academic Institution: I certify that I have graduated. A copy of my qualification is attached. Date of graduation: Were you enrolled full-time in your academic program? Qualification type: Field of study:
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Yes

No

12-Month U.S.A. Intern Work Programme

Participant Application
Program Information
The information you provide below is meant to give USIT, as well as CIEE, a better understanding of your goals and objectives. The Applicant understands that approval of this application in no way guarantees approval of applicants internship once in the U.S. CIEE can only determine the viability of an internship once a signed DS-7002 has been submitted for review.

1. In which industry, or type of company, do you hope to find your internship?

2. What is your most recent field of study?

3. How will completing an internship in the above-mentioned industry or company further your goals as related to this field of study?

4. Identify as best you can the skills and knowledge you aim to acquire from your internship in the U.S.

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CIEE 12-Month U.S.A. IWP Last updated: 2010.10.01

12-Month U.S.A. Intern Work Programme

Participant Application
Participant Declaration
ThefollowingsectionservestooutlinethetermsandconditionsofyourparticipationontheCIEE12-MonthU.S.A.InternWorkProgramme.Werequire thatyoucarefullyreadthefollowinginformation,andconfirmthatyouhaveread,understood,andagreetothesetermsbysigninganddatingthelast page.Ifyoufailtosignordatethissection,wewillbeunabletoprocessyourapplicationuntilyouhavedoneso. SECTION I. Applicant Responsibilities 1.TheApplicantagreesthatalltheinformationprovidedintheapplicationistruetothebestofhisorherknowledge,andacknowledgesthatanyfalse ormisleadinginformationmayleadtotherejectionoftheapplicationor,ifdiscoveredlater,toimmediatedismissalfromtheprogram. 2.TheApplicantisresponsibleforconsideringhisorherpersonalhealthandsafetyneedswhenapplyingforandparticipatingintheprogram.Ifthe Applicantsuffersfromanyhealthorotherconditionthatwouldcreateariskforhimorherwhileabroad,heorsheshouldnotapply. 3.TheApplicantagreestopayallfeesinaccordancewiththeproceduresoutlinedbyUSITIreland. 4.TheParticipantagreestopurchasetheirflightstotheU.S.fromUSIT.ThesecanbebookedthroughaUSITbranchofficeortheUSITCallCentre. Purchasingticketsonlineorwithanotherorganizationwillbedeemedaviolationofprogramrulesandparticipantswillbewithdrawnfromtheprogram. Inthiscase,fullcancellationfeeswillapply. 5.TheApplicantisresponsibleforsubmittingallrequesteddocumentationtoUSITwithinthetimeframesrequiredbyUSITfortimelyprocessing.USIT/ CIEEcannotbeheldresponsibleforanyadditionalcostsincurred(includingthecostofrebookingorcancellingaflight)bytheApplicantduetodelays insubmittingdocumentationordelaysbytheU.S.Embassyinissuingavisaorvisadenial. 6.TheApplicantmustpaythelocalvisafeetotheU.S.Embassy.TheApplicantisalsoresponsibleforanyadditionalvisafeesthatmightapplyatthe U.S.EmbassyinDublin,aswellasthegovernmentSEVISfeecollectedaspartoftheapplication. 7.TheApplicantwillneedtocompleteaninterviewwithUSITIrelandinordertoparticipateintheprogram. 8.TheApplicantmustsupplyUSIT/CIEEwiththenameandcontactdetailsofnextofkintobecontactedinthecaseofemergency. 9.TheApplicantmustnotsubmitaprogramapplicationwiththeintenttoworkintheU.S.inprohibitedpositionsincluding;asanaupair,childcaregiver, teacher,teachingassistant,campcounselor,inaprivatehousehold,asashiporaircraftcrewmember,asmedicalstaffhavingpatientcontact,orinany unskilledposition.Foracompletelistofunskilledpositions,pleaserefertotheDepartmentofStateslistfoundhere:exchanges.state.gov/jexchanges/ private/trainee_unskilled.html. 10.USIT/CIEEmayissueaDS-2019FormiftheApplicantmeetsallrelevantprogramrequirements.However,USIT/CIEEhasnocontroloverthedecision oftheU.S.EmbassyinDublintoissueaJ-1Visa. 11.TheApplicantunderstandsthatapprovalofthisapplicationinnowayguaranteesapprovalofapplicantsinternshiponceintheU.S.CIEEcanonly determinetheviabilityofaninternshiponceasignedDS-7002hasbeensubmittedforreview. SECTION II. General Program Participant Responsibilities 1.TheParticipantisresponsibleforreadingandcarefullyconsideringallmaterialsmadeavailabletohimorherthatrelatetosafety,health,legal, environmental,political,culturalandreligiouscustomsandconditionsintheU.S.TheParticipantmusttakefullresponsibilityintheeventthatlaws, regulations,orcustomsarebroken,regardlessofhisorheractualknowledgeoftheselaws,regulations,orcustoms. 2.Inadditiontoreviewingallprogrammaterials,theParticipantisrequiredtocompleteaCIEEorientation. 3.TheParticipantmustexerciseduecareonceinpossessionofthelegaldocumentation(DS-2019,DS-7002,J-1Visa,etc.)fortheprogram.(TheDS2019 documentmustbeonyourpersonuponenteringtheU.S.andallotherdocsmustbeheldincarefulpossessionduringyourentirestay.)TheParticipant shouldbeadvisedthatthesedocumentsaredifficulttoreplaceandthatsheorheshallbearthecostofreplacingtheseitemsiftheyarelost. 4.TheParticipantisresponsibleforallofhisorheractsalongwithanyresultinglossordamagewhileontheprogram.TheParticipantagreesto indemnifyandholdharmlessUSIT/CIEEfordamagesorlosstoanypartycausedbyhisorherconduct. 5.Alltravelbefore,during,andaftertheprogramisattheParticipantsownrisk.Also,iftheParticipantchoosestooperatemotorizedvehicles,heorshe isresponsibleforobtainingthenecessarylicense,permission,andinsurance,anddoessoathisorherownrisk. 6.OncetheParticipanthascommencedhisorhertraveltotheU.S.,USIT/CIEEcannotamendtheprogramdatesaslistedontheDS-2019.Itisthe ParticipantsresponsibilitytochecktheprogramstartandenddatespriortotravelingtotheU.S.toensurethatthedatesarecorrect. 7.IfduringthecourseoftheprogramtheParticipantencountersanydifficultieswithhisorherinternship,orwithsafety,health,orhousing,the ParticipantshouldnotifyCIEEassoonaspossiblebycallingCIEEat1.888.268.6245.Intheeventofanemergency,theParticipantcanalsoreachCIEEat theabovenumberanytimenightorday. 8.TheParticipantisrequiredtocomplywithallU.S.Governmentvisaandimmigrationrequirements,includingtheSEVISrequirementasfollows: a)ConfirmationofU.S.homeaddresstoCIEEwithin10 daysoftheDS-2019programstartdate. b)NotificationtoCIEEofany changeinU.S.homeaddresswithin10 daysofthechange. 9.TheParticipantagreesthatheorshewillnotengageinanyactivitythatwouldbringthe12-MonthU.S.A.InternWorkProgrammeortheU.S. DepartmentofStateintonotorietyordisrepute.TheParticipantshouldcontactCIEEforguidanceifanyproposedactivitymightcausethisresult.

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CIEE 12-Month U.S.A. IWP Last updated: 2010.10.01

12-Month U.S.A. Intern Work Programme

Participant Application
10.Theparticipantagreestocompleteanevaluationatthemid-pointandendoftheprogram. SECTION III. Participant Responsibilities with Respect to His or Her Internship Placement 1.TheParticipantunderstandsandagreesthatitishisorherresponsibilitytolocateasuitableinternshippositiononceintheU.S.Thepositionmust adheretoU.S.StateDepartmentguidelinesforthe12-MonthU.S.A.InternWorkProgrammeasfollows: Benolongerthan12-monthsintotalduration BerelatedtoParticipantsfieldofstudy NotbeinanyoftheprohibitedfieldsnotedaboveinSection I, 9.

2.TheParticipantagreestoprovideCIEEwiththename,location,andfullcontactdetailsofhisorhersupervisorfortheprospectivecompany immediatelyuponlocationoftheinternshipandrequestaFormDS-7002template(theU.S.StateDepartment-requireddocumentationoftheinternship placement)throughtheCIEECustomerServiceCenter.Further,theParticipantunderstandsthatheorshemustsubmittoCIEEtheFormDS-7002fully completedandsignedbyhisorheremployer.Finally,theparticipantunderstandsthatheorsheshouldnotbegintheinternshipbeforetheDS-7002is approvedbyCIEE. 3.IftheproposedinternshipasoutlinedonFormDS-7002andsubmittedbyParticipantdoesnotmeetprogramrequirements,CIEEreservestherightto rejecttheinternshipandrequirethatParticipantlocateanotherposition. 4.IfParticipantfailstonotifyCIEEofhisorherinternshiplocationand/orsubmitadulycompletedandexecutedFormDS-7002,CIEEreservestheright towithdrawprogramsponsorshipandrequirethattheParticipantreturnhomeinaccordancewithU.S.StateDepartmentpolicy. 5.USIT/CIEEcannotguaranteetheavailabilityofinternshippositionsoncetheparticipantisintheU.S.CompletionofFormDS-7002byahost organizationdoesnotconstituteabindingcontractbetweenhostorganizationandParticipant.ShouldParticipantbeletgofromhisorherinternship positionatnofaultofhisorherown,theParticipantisauthorizedtolocateanewposition. 6.USIT/CIEEarenotresponsibleforanyexpensesincurredbytheParticipantifheorshehasnotstartedaninternshipbytheagreeddateduetoany circumstancesnotunderthedirectcontrolofCIEE. 7.USIT/CIEEarenotresponsibleforaParticipantsinabilitytoobtainaninternshippositiononceintheU.S.AnyparticipantwhoreturnstoIrelandasa resultofnotfindingasuitablepositionintheU.S.doessoattheirowndecision,andnorefundwillbegiven. 8.TheParticipantmayonlyinternatthehostorganizationlistedonFormDS-7002andapprovedbyCIEE.Ifforanyreasonachangeofhostorganization becomesnecessary,theParticipantmustcontactCIEE,submitanewDS-7002,andreceivewrittenapprovalfromCIEEbeforechanginginternships. Casuallaborand/orsecondjobsarenotpermittedonthisvisa.FailuretocomplywiththeseregulationswillresultintheParticipantswithdrawalfromthe program. 9.IftheactualinternshippositiondeviatessignificantlyfromthetermssetforthinFormDS-7002,oriftheinternshipenvironment,forwhateverreason, provesunsupportive,theParticipantshouldcontactCIEEdirectly.Ifwarranted,CIEEwillendeavortoassisttheParticipantinfindinganotherposition. However,CIEEmakesnoguaranteethatitwillbeabletodosoand,furthermore,makesnorepresentationthatitwillbeabletofindaninternship positionfortheParticipantinthesamegeographicalarea,inthesamefield,oratthesamecompensationlevel.TheParticipantisfreetosecurean alternativeplacementinaccordancewithInternshipguidelinesasabove. 10.TheParticipantagreesnottoengageintraininginanyunskilledorcasuallaborpositions,inpositionsthatrequireorinvolvechildcareoreldercare, orinanykindofpositionthatinvolvespatientcareorcontact.Furthermore,Participantalsoagreesnottoengageintraininginapositionthatinvolves morethan20percentclericalwork. 11.IftheParticipantsoriginalinternshipprogram,forwhateverreason,endspriortotheenddatelistedonFormDS-2019,itistheParticipants responsibilitytoinformCIEEassoonasthisisknown. SECTION IV. Participant Responsibilities at the Conclusion of the Program 1.TheParticipantagreesthatheorsheintendstoreturnhomeuponcompletionoftheprogramandnottoattempttostayintheU.S. SECTION V. Contractual Terms and Other Program-Related Conditions 1.The12-MonthU.S.A.InternWorkProgrammeApplication,includingthisParticipantDeclaration,isthebindingcontractbetweentheParticipantand CIEE. 2.CIEEmakesnorepresentationorwarrantyofanykind,expressedorimplied,astothesuitabilityoftheprogramfortheParticipant,andCIEEdisclaims allsuchwarrantiestothefullextentofthelaw. 3.Theconductofthe12-MonthU.S.A.InternWorkProgrammeissubjecttoU.S.governmentapprovalandmaychangewithoutnotice. 4.CIEEdoesnotownoroperateanyentitywhichprovidesgoodsorservicesfortheprogram,includingbutnotlimitedtoarrangementsforor ownershiporcontroloverhouses,apartmentsorotherlodgingfacilities;airline,vessel,busorothertransportationcompanies;foodservice;or entertainmentproviders.AllsuchpersonsandentitiesareindependentcontractorsandenterintolegalrelationshipsdirectlywiththeParticipant(and notthroughCIEE).Asaresult,CIEEisnotliableforanyactorfailuretoactofanysuchpersonorentity,orofanythirdparty.Withoutlimitation,CIEE isnotresponsibleforanyinjury,loss,ordamagetopersonorproperty,death,delayorinconvenienceinconnectionwiththeprovisionofanygoodsor servicesoccasionedbyorresultingfrom,butnotlimitedto,actsofGod,forcemajeure,actsofwarorcivilunrest,insurrectionorrevolt,strikesorother laboractivities,criminalorterroristactivitiesofanykind,overbookingordowngradingofaccommodations,structuralorotherdefectiveconditions ofhouses,apartmentsorotherlodgingfacilities(orinanyheating,plumbing,electricalorstructuralproblemtherein),mechanicalorotherfailure ofairplanesorothermeansoftransportationorforanyfailureofanytransportationmechanismtoarriveordeparttimely,dangersassociatedwith domesticorwildanimals,sanitationproblems,foodpoisoningdisease,lackof,accesstoorqualityofmedicalcare,difficultyinevacuationincaseof medicalorotheremergency,orforanyothercausebeyondthedirectcontrolofCIEE. 5.TheParticipantagreesthatanydisputeconcerning,relating,orreferringtotheInternshipPlacementPlan,the12-MonthU.S.A.InternWork www.ciee.org 9 CIEE 12-Month U.S.A. IWP Last updated: 2010.10.01

12-Month U.S.A. Intern Work Programme

Participant Application
ProgrammeApplication,anyotherliteratureconcerningtheprogram,ortheprogramitselfshallberesolvedexclusivelybybindingarbitrationinthe StateofMaine,accordingtotheexistingrulesoftheAmericanArbitrationAssociation.SuchproceedingswillbegovernedbyStateofMainelaw. 6.USIT/CIEEreservestherighttorefusesponsorshiptoanyapplicantwhoUSIT/CIEEdeemsdoesnotmeetprogrameligibilityrequirementsor anyapplicantwhoUSIT/CIEEdoesnotdeemappropriatetoacceptinthegeneralinterestsoftheprogram.IntheeventthatUSIT/CIEErejectsthe Applicantsapplicationtotheprogram,anyapplicablerefundwillbemadeviaUSITIreland. 7.ProgramparticipationbeginsonthedayofdeparturefromtheparticipantshomecountryandterminatesonthedayofdeparturefromtheU.S. (solongasthisoccurswithinthelegalprogramdates).Themaximumlengthofthe12-MonthU.S.IWPprogramofferedthroughUSITandCIEEis12 months.TheexactdurationofstayintheU.S.mustbeconfirmedbyParticipantpriortohisorherdeparturetotheU.S. 8.TravelInsuranceismandatoryforallparticipantsontheprogram.MinimumlevelsofinsurancecoveraredeterminedbyU.S.StateDepartment RegulationsanditisalegalrequirementoftheU.S.GovernmentthatParticipantshaveadequateinsurancecoverforthetotaldurationoftheirstayin theU.S.,includinganyoptionaltravel.ItistheresponsibilityoftheParticipanttoensureheorshehastheappropriateinsurancecoverage. FullpolicydetailsandoptionscanbeobtainedbyParticipantthroughUSITandastheinsuredpersontheParticipantmustguaranteethatheorshe complieswiththetermsandconditionsofUSITsinsurancepolicyandtheinsurersmustbeinformedofanyfactwhichislikelytoinfluencetheInsurersin theacceptance,assessmentorcontinuanceofthisinsurance.FailuretodosomayinvalidatetheinsuranceleavingtheParticipantwithnorighttomake aclaim. 9.CIEEreservestherighttodismisstheParticipantfromtheprogramif,initsbestjudgment,theParticipantisdeemedtobeadangertohim-orherself ortoothers,orifhisorherconductisdeemedtobedetrimentaltotheprograminanyway.Intheeventofsuchadismissal,CIEEshallnotbeheld responsibleforanyresultingexpensesincurredbytheParticipantsuchasairfare,andshallnotberequiredtoreturnanyfeespaidbytheParticipant. 10.OncetheParticipanthasdepartedfortheU.S.,heorshewillreceivenorefundshouldheorshechoosetowithdraworterminatehisorherprogram. TheParticipantwillalsoreceivenorefundshouldCIEEfinditnecessarytowithdrawsponsorshipaftertheParticipanthasdepartedfortheU.S.Also, CIEEisnotresponsiblefortherefundofanyfeespaidtothirdparties(e.g.,theU.S.Embassy,SEVIS,airlines,etc.),regardlessofthecircumstances. 11.CIEEdoesnotprovidehousing.TheParticipantwillneedtoarrangehisorheraccommodationindependentlyfortheprogram.Thiswilllikelyrequire thatheorshesignaleaseandpayadeposit,whichusuallyamountstothefirstandlastmonthsrentandmayincludeanadditionalsecuritydeposit. 12.CIEEmayprovidetheparticipantscontactinformationtothirdpartieswhoprovideusefulservicestoexchangeprogramparticipants.Thirdparties receivingthisinformationwillberequiredtoprovidetheparticipantwiththeopportunitytooptoutafterthefirstcontact.

Participant Signature
Bysigningbelow,youindicatethatyouhaveread,understoodandagreetoalltermsoutlinedintheParticipantDeclarationsectionandthatyou havebeenmadefullyawareoftherequiredplacementprocedures/regulationspriortocompletingyourapplicationfortheprogram.Additionally, bysigningbelow,youalsoconfirmthat,tothebestofyourknowledge,allinformationcontainedinthe12-MonthU.S.A.InternWorkProgramme Applicationistrueandaccurate.

Participant Signature:

Date:

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CIEE 12-Month U.S.A. IWP Last updated: 2010.10.01