Host Employer Information
Please note, all fields are required. If not applicable, enter "NA".

Annual Revenue:

Number of (on annual basis):

J-1 Interns/Trainees



Is English the main language used when communicating to Participant and your staff?
Will the Participant train/work alongside U.S. employees daily?
How many full-time U.S. employees will the Participant train/work alongside on a daily basis in his/her program?

Is this a staffing employment agency?
Will your Intern/Trainee program involve more than 20% clerical work?
Have you laid off staff in the past 120 days?

Previous Experience with the J-1 Program
Have you hosted Interns/Trainees in the past three years?
Have you hosted Work and Travel Participants in the past three years?

If yes, please list the Sponsor Organizations:

Training/Work Information
Is pre- employment drug test required?

Are tests or similiar required for the Participant to complete his/her program?

Please outline the position titles the Participant will train/work

Position Title Rate of Pay
Is the employer able to guarantee a minimum of 32 hours per week?
If Participant trains/works more than 40 hours in a week, will the Participant be paid overtime?
Will the Participant ever be required to train/work more than 50 hours per week?
Can the Participant begin without Social Security Number?
Will the Participant be able to receive a paycheck before the SSN is issued?
Are there any circumstances that would delay the Participant from starting immediately upon arrival?

Will the Participant be required to pay Union Dues?
If yes, amount:
Are meals provided during shift?
If yes, cost:

Housing Information
Does employer provide housing?

If No, can the employer provide two week hotel stay and assistance in securing housing?

What can a participant expect to pay on a monthly basis at these referrals?
Employer Provided Housing Please Complete the Following

Housing address, complex name:
Cost of housing:
Estimated Cost or Other Utilities:

Utilities Included?

Is housing furnished?

Are there cooking facilities available?

Cooking Facility Details:
Is a lease or housing agreement signed?

Transportation Information
Does employer provide transportation from airport to host site?

Is daily transportation provided

Will Participant use bicycles as transportation?



You must sign the agreement on the next page to complete your application.

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