Application Paperwork English _Antragsformular ... - AHK New York by cuiliqing


									                              J-1 Exchange Visitor Program – Participant Application Form
Please make sure to type or clearly print the information requested in each of the fields. Please indicate “N/A” or “None” instead of leaving fields
blank. Failure to complete the application and sign the paperwork will result in the delay or rejection of your application.

                          Last Name (family name)

                          First Name                                                                   Other Name(s) (as listed on passport)

                          Date of Birth (mm/dd/yyyy)           City of Birth (as listed on Passport)                    Country of Birth

                          Country of Citizenship                              Passport Number                           Passport Expiration Date (mm/dd/yyyy)

                          Country of Permanent Legal Residence                Marital Status:                                    Single                Married
                                                                              Gender:                                            Male                  Female
Current (Academic)             Student (minimum of 1 completed university semester)
                               Apprentice/Vocational Trainee
                               Recent Graduate ( within 12 months of graduation)                   Date of Graduation (mm/yyyy)
                                                                                                   (please attach certificate if possible)
Internship Dates                                                                                 Please inform the GACC if you plan to travel more than 7 days
(mm/dd/yyyy)              Date of Departure to US:                                               before your start date.
                                                                                                 You must enter no more than 15 days after the start date unless
                          Program Start Date:                                                    approved by the GACC.
                          Program End Date:
                          Date of Return to Home Country:                                         Must be no more than 30 days after training end date.
                          Street Address

(all documents will be Postal Code                     City                                             State (if necessary for mail)        Country
sent to this address)
                          Telephone                               Mobile Phone                                           Email
Permanent Address
                          Street Address
      Check here and
                       Postal Code                     City                                             State (if necessary for mail)        Country
do not complete if
the information is the
same                   Telephone                                  Mobile Phone                                           Email
Emergency Contact

(must be a relative,      Full Name                                                                     Relationship to You
spouse, or guardian)
                          Street Address

                          Postal Code                  Postal Code                                      State (if necessary for mail)        Country

                          Telephone                               Mobile Phone                                           Email
Information                    No dependents will be accompanying me.             My spouse            My child(-ren) will accompany me. (Number of Children       )
(please check             Please be aware that you need to inform the GACC if you wish to bring any dependents. You will be given an additional form for each
applicable boxes)         dependant.

                    75 Broad Street, 21st Floor – New York, NY 10004 Tel: 212-974-8845 – Fax: 212-752-3164 – Email: –
                                                                                  Page 1 of 4
                         Have you ever received a J-1 visa to enter the USA?      Yes      No                    If “yes,” how many?
Visa Information         If “yes” type of program:
                         Have you ever applied for a US work permit or to immigrate permanently to the US?                                             Yes     No
                         Have you ever been refused a visa by a US Embassy/Consulate?                                                                  Yes     No
                         Have you ever been arrested and convicted of a crime in your home country?                                                    Yes     No
                         Have you ever been arrested and convicted of a crime in the US?                                                               Yes     No
                         Are you currently in the US?
                               If “yes,” what type of visa?                                                                                            Yes     No
                         Have you in the last 12 months entered the US?
                               If “yes,” what type of visa?                                                                                            Yes     No
                         Host Employer/Organization in the US

                         Street Address

                         City                                           State                                               Postal Code
Contact                         Mr.   Ms.    Dr.
Information                                              Name of Contact Person                                    Title

                         Telephone                                      Fax                                                 Email
Education or
                         Name of Technical School, University or Vocational Training Institution     City                                   Country
(Please list your
                         Begin Date (mm/dd/yyyy)                                                            End Date (mm/dd/yyyy)
most recent
                         Area of Study/Vocational Training                                                  (expected) Degree
Financial Security       IMPORTANT: All participants must show financial support of at least $1,500 per month for their entire stay in the US. Support can come
Statement                from the host company, applicant’s personal savings, or from the applicant’s parents.
                         For Example: If you earn $500 per month from your host company, you will have to show that you have private funds of at least $1,000
                         per month. For a 6 month position you must show private funds totaling $6,000 providing the GACC with a bank statement or financial
                         security statement from your parents.
                         If you are being paid in Germany (Euro), please attach proof of salary.
(Check One)                 The wage I earn totals $1,500 or more per month as shown by my host company on form DS7002.
                            The wage I earn is less than $1,500 per month. I have attached a bank stamped statement for the total amount required.
                            The wage I earn is less than $1,500 per month. I have attached a letter from my parents.
Statement of             Your application has to include a Statement of Motivation which should explain your motivation for participating in the GACC’s
Motivation               educational exchange program. How has your background prepared you for this internship or practical training? Describe how this
(Please write in         experience will benefit you in terms of your career development and/or academic pursuits. What projects will you participate in at while
English and sign)        at your host company? How will you use this experience in your home country?
                         Your statement should be in typed letter format, between 150 and 300 words addressed to Mr. Thomas Dzimian on a separate sheet of
                         paper. Please make sure to sign your letter and include it as part of your application packet.

References               Please also provide us with two references. We accept references from (former) teachers, professors or employers.

                         Please attach a copy of your passport. It is not required that your passport has biometric data, however it should must be valid for the
Copy of Passport
                         entire duration of your internship including the additional 30-day grace period.

                         You can verify your English ability by submitting one of the following: copy of an official score that you received on an English exam
English Ability          (TOEFFL/Cambridge, not more than two years ago), a letter (written in English) or a test form (you can find a template on our website)
                         from a qualified English instructor or by taking a telephone test with a GACC representative.

Certification            Please certify with your signature on page four that you have read, understood and agree to all the information given to you by the
Statement                GACC including the J-1 visa rules and regulations.

                    75 Broad Street, 21st Floor – New York, NY 10004 Tel: 212-974-8845 – Fax: 212-752-3164 – Email: –
                                                                                  Page 2 of 4
                                                                                                                                                                    Form Year: 2008
Health Insurance     As a participant of the GACC’s J-1 Exchange visitor program you have the option of participating in a group health insurance administered by
  Information        the GACC or providing the GACC with a sufficient proof of alternative health insurance coverage. The GACC group insurance is provided by
                     Aetna. Aetna is one of the leading Health Insurance Providers in the US.

                     By enrolling in the program with GACC you acknowledge the insurance terms and conditions as well as exclusions.

                     The insurance package exceeds all Department of State guidelines for J-participant health insurance and includes among others the
                     following benefits:

                     Accidental Death and Accidental Dismemberment Benefit                    $ 100,000
                     Medical Evacuation Benefit                                               $ 30,000
                     Repatriation of Remains Benefit                                          $ 10,000

                     Please note the following exclusions to the medical plan:

                                Routine physical or other preventative examinations (e.g. dentist)
                                Pre-Existing Conditions and illness or injury as a result
                                Injuries resulting from certain hazard (e.g. snow sports, mountain climbing)

                     This description of insurance benefits is only a summary and does not include all benefits and exclusions.
                     For more detailed information visit our website ( under J-1 Visa Service – Insurance information.

                     Participants will be covered for the entire duration of their program duration plus 30 days following completion of program.

                     Please indicate your insurance option:

                           1.          I acknowledge the insurance terms and condition and I participate in the insurance program of the GACC.

                     Please certify:               I have read and understood the insurance information distributed to me by the GACC.
                                                   I have no pre-existing conditions.
                                                       I am aware of a pre-existing condition and informed the GACC. I have secured alternate insurance to
                                                      cover my pre-existing condition. (Please check only if this is applicable)
                                                   I understand that there are risks associated with living abroad and do not hold the GACC liable for any illness
                                                       or injury that I incur while participating in the program.
                                                   I understand that I am covered for 7 days prior to the start date and 30 days after the end date on my DS-2019.

                           2.          I am already covered by an insurance carrier in my home country. I hereby confirm that this insurance covers the
                                       following benefits:

                                Accidental Death and Accidental Dismemberment Benefit                $ 100,000
                                                                                                          $ 100,000
                                Medical Evacuation Benefit                                           $ 30,000
                                Repatriation of Remains Benefit                                      $ 10,000

                                                     This insurance will cover the entire duration of my program plus 30 days following its completion.
                                                     I have attached a copy of the insurance policy including coverage dates.

                     Signature                                                                        Date (mm/dd/yyyy)

                   75 Broad Street, 21st Floor – New York, NY 10004 Tel: 212-974-8845 – Fax: 212-752-3164 – Email: –
                                                                                 Page 3 of 4
                                                                                                                                                                     Form Year: 2008
  Section I: General Rules and Guidelines for the J-1 Visa                                    13. Participants must follow all instructions from the GACC before and during their
  1. The German American Chamber of Commerce (GACC) is a nonprofit organization                   stay in the US and comply will all applicable laws, regulations and/or instructions
     authorized by the United States Department of State (DoS) to sponsor program                 of appropriate government agencies in the US.
     participants under the J-1 Exchange Visitor visa.                                        14. Participants are solely responsible for any penalty resulting from their conduct
  2. The GACC is authorized by the DoS to issue the Certificate of Eligibility DS-2019.           illegal or otherwise which harms another or damages property while participating
     This document allows participants to attain a J-1 visa at a US Consulate in their            in the GACC’s program.
     home country.                                                                            15. Should the participant choose to terminate the program earlier than planned,
  3. The GACC does not support activities in “unskilled occupations” (22 C.F.R. § 62.22,          he/she must inform the GACC in writing, return the DS-2019 to the GACC and exit
     Appendix E) such as home health care, child care, door-to-door sales,                        the country within 14 days of notice.
     telemarketing, gardener, etc. The GACC also cannot support activities in areas of        16. Participants are responsible for all debts and expenses incurred during their stay
     patient care, flight training, ship and aircraft crew, teacher or teaching assistant,        in the US. Participants must agree to pay all outstanding debts before leaving the
     and in the fine or performing arts and any positions with more than 20% clerical             US.
     tasks.                                                                                   17. Participants may not under any circumstance hold a second job outside of their
  4. The time allowed for internships is limited to a maximum 12 months. All positions            activity at the host company listed on their DS-2019. Failure to comply will result
     must be full-time with a minimum 35 hours per week.                                          in the participant’s immediate termination from the GACC’s program.
  5. The DS-2019 Certificate of Eligibility is issued to reflect the dates of the program.    18. Participants must inform the GACC prior to any trips outside the US with the
     Participants are allowed to stay for 30 days beyond the end date, so long as this            exception of Mexico and Canada. Participants must receive a travel validation on
     period is not used for additional training or employment.                                    their original DS-2019 prior to any initial trips outside the US. Travel validations
  6. The GACC can withdraw sponsorship if any of the conditions of the program are                are valid for up to 12-months.
     altered without the GACC’s advance permission. If sponsorship is withdrawn, the          19. Travel outside the US may not be more than 2 weeks during any 12 month period.
     participant must leave the US immediately.                                               20. Participant insurance only covers incidental visits outside the US for periods less
  7. The GACC has no influence on the actions of the US Consulates abroad. The GACC               than 2 weeks. Should extreme situations warrant an additional travel allowance
     is not responsible and can neither help nor interfere with Consulate-related issues          participants must inform the GACC prior to travel and secure appropriate
     including visa processing time, Consulate appointments, or visa rejections.                  insurance. Failure to do so will result in the termination of participation in the
  8. The GACC takes no responsibility if participants must rebook flights because of              GACC’s program.
     delays resulting from the Consulate, or by late submission of paperwork by either        21. Participants must complete a midterm and final evaluation for any program over
     participant or host company.                                                                 three months in length. Evaluations should be discussed with participant’s
9. The GACC is not responsible for time lost on the DS-2019 should a participant                  supervisor and signed prior to being returned to the GACC.
     arrive in the US later than the start date as listed on the DS-2019.                     22. If dependants are to accompany participants to the US, participants must secure
10. No individual who is out-of-status or who has overstayed any duration of stay                 appropriate insurance for each of their dependants. Insurance must meet the
     with any other visa type will be considered for GACC sponsorship.                            following requirements: accident insurance coverage up to $50,000 per sickness
11. The GACC reserves the right to deny sponsorship to any individual whom it does                or accident, repatriation expenses up to $10,000 for remains, and coverage for
     not deem appropriate for program participation.                                              medical evacuation to participant’s home country in the amount of $7,500. This
12. The GACC will not proceed with the issuance of a DS-2019 without signed and                   coverage must cover the entire duration of the dependant’s stay including the 30
     completed paperwork, including receipt of all GACC fees.                                     day grace period. Insurance policies must be submitted for GACC’s review prior to
                                                                                                  the issuance of the J-2 dependant visa.
Section II: Responsibility of Program Participants                                            23. Participants agree to return home upon completion of their program and not to
 1. It must not be the intention of the participant to abandon his/her permanent                  attempt to remain in the US to pursue employment.
     home-country residence and/or citizenship.                                               24. The GACC is not responsible for expenses incurred due to a participant not
 2. It is forbidden to apply for a J-1 visa in conjunction with filing for any other US           beginning by the agreed date due to weather, illness, or other situation/condition
     non-resident alien visa.                                                                     either at his/her host company or occurring to the participant directly.
 3. Participants are responsible for considering all risks to health and safety that may      25. Participants are required to inform their host company and seek a solution if they
     occur in conjunction with living for an extended period of time in a foreign                 are experiencing problems or difficulties before contacting the GACC.
     country. If a participant suffers from any condition that may impede program             26. Participants may not train in addition to or transfer to another host company
     participation, it is required that this is disclosed to the GACC prior to the issuance       unless they inform the GACC prior to accepting the offer and the current host
     of the DS-2019.                                                                              company agrees to release the participant.
  4. Participants are required to cover all fees associated with visa application
     including Consulate fees and the SEVIS fee in conjunction with the DoS data              Section III: Responsibility of the GACC to the Host Company and Participant
     collection system.                                                                         1. A full refund of the administrative fee will only be given if the DS-2019 has not
  5. Participants must schedule and attend an in-person interview at the US Consulate              been issued. Once the DS-2019 has been issued only 50% of the visa fee will be
     in their home country in order to receive their J-1 visa.                                     refunded. If the participant already received his/her J-1 visa and/or has entered
  6. Participants are responsible for reading all orientation information available                the US on a J-1 visa no part of the visa fee will be refunded.
     online and in the information packet distributed by the GACC.                              2. The GACC will assure that participants are covered by adequate health and
7. Participants must have $300 in cash in their possession when entering the USin                  accident insurance within the DoS guidelines. All appropriate measures have been
     order to cover all initial expenses.                                                          taken to ensure that participants without preexisting conditions and not engaged
8. Participants must enter the US no later than 15 days after the start date listed on             in extreme or dangerous sports are covered by the GACC group insurance policy.
     the DS-2019. Failure to do so or to inform the GACC may result in additional fees             Policy descriptions and benefits are detailed on the GACC website. Insurance will
     and penalties or visa termination at the discretion of the GACC.                              be refunded excluding months in which coverage was provided and less $120
9. Participants must return their “Check-In” form to the GACC within the first 15                  administrative fee after the start date on the DS-2019.
     days of entering the US. Failure to do so may result in additional fees and                3. Participants will be covered by insurance 7 days prior to their start date and 30
     penalties or visa termination at the discretion of the GACC.                                  days after the end date on their DS-2019. Claims made outside these dates will be
10. Participants are required to inform the GACC of their current US mailing address               rejected.
     and update this information should it change during the time they are in the US.           4. The GACC cannot assist participants with insurance claims issues and does not
11. All Participants must apply for a Social Security Number. Please wait                          have access to participant medical records. Every attempt should be made to
     approximately one week after entering the US and 48 hours after submitting your               contact the insurance company directly before contacting the GACC. The GACC
     “Check-In” form before applying.                                                              cannot be held liable for any unresolved claims or coverage issues.
12. The GACC is the legal sponsor for all participants in the J-1 visa program. All             5. The GACC will submit an annual report to the DoS in the form prescribed by the
     participants must agree to consult directly with the GACC before changing any                 DoS, reviewing the status of the Exchange Visitors in the US.
     aspect of their program participation.                                                     6. The GACC cannot speak for third party services or organizations it recommends to
                                                                                                   its participants nor make any guarantees about their services and fees. Use of
                                                                                                   such organizations is strictly at the discretion of the participant.

I certify the information that I have included as part of this application is truthful in its entirety. I have read and understood the information listed above. I agree to
abide by all the rules applicable to me as a participant in the GACC J-1 Exchange Visitor Program. Further I understand my responsibilities to my host company and to
the GACC as well as their responsibilities as they relate to my program. Should I encounter problems or have any concerns while I am in the US I will contact the GACC
for guidance.

Participant’s Signature                                                                          Date (mm/dd/yyyy)

                      75 Broad Street, 21st Floor – New York, NY 10004 Tel: 212-974-8845 – Fax: 212-752-3164 – Email: –
                                                                                    Page 4 of 4
                                                                                                                                                                             Form Year: 2008

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