Full Service Application

Please type or print neatly in black ink, and fill out form completely. Send the completed application to your Work & Travel USA/InterExchange representative.
Last Name First Name Middle Name

Present Street Address Telephone Number

City Postal Code

Attach photo here.

Country Valid Until smile

Permanent Street Address Telephone Number Photos should be no larger

City Postal Code than the space provided here.

Country Valid Until

City of Birth Country of Birth E-mail Address

Country of Perm. Residency Country Issuing Passport Country of Citizenship

Date of Birth: Month Day Year

Male Female Single Married

Work/Leadership/Volunteer Experience: Please list the most recent/current experience first. Please provide at least one supporting reference, translated into English.
TYPE OF WORK/TITLE DUTIES NAME OF ESTABLISHMENT DATES

Hobbies and Skills: Please check all the areas that best describe your primary interests.

Cooking Gardening Theater/Movies Do-It-Yourself Swimming Horseback Riding Skiing Writing

Photography Artwork Dance Computers Tennis Sailing Bicycling Football

Singing Musical Instruments: Other:

Do you have a national driver’s license? Yes No Do you have an international driver’s license? Yes No Office use only

Do you have a lifeguarding certificate? Yes No Do you have coaching experience? Yes No

Field of study Other subjects studied

Have you ever been to the U.S.? Yes No If yes, when? With which program?

Other travels (not in the United States)

Type of Job Desired: (Please refer to Job Information section of Program Brochure)

1. 2. 3.

Location desired: (Please refer to Job Information section of Program Brochure)

1. 2. 3.

U.S. Arrival Date (mm/dd/yy) Last Day of Work (mm/dd/yy)

InterExchange, Inc.

2007 161 Sixth Avenue, New York, NY 10013

TEL: 212 924-0446 FAX: 212 924-0575
[email protected] www.WorkTravelUSA.org
University Presently Attending Are You a Full-Time Student? Yes No

Date of Initial Enrollment Estimated Date of Graduation

Years of English Total ___________ Secondary School___________ University ___________ Other Languages Spoken

How did you hear about the Work & Travel USA program, and why did you decide to participate?

Please use this space for special requests, or for any additional comments about yourself which would be useful when considering your application and any special placement requests, i.e. with friends, partners,
etc. (not all requests can be accommodated).

In order to best meet your expectations for the program, please rate which is most important to you:

Saving Money Traveling Skiing (Winter Only) Comments:

Do you smoke? Yes No Occasionally If yes, how much?

State of Health and Remarks: Include any allergies, special diets, religious obligations or any physical/mental conditions that could affect your participation and placement in a particular area. Please use extra
paper if necessary. This information is very important, and failure to report fully on the state of your health may result in inadequate health insurance coverage while in the United States.

Release of Medical Records: In case of medical emergency or hospitalization, I hearby authorize any medical institution or healthcare professional to release my medical records to an InterExchange
Representative to ensure that all necessary measures are taken on my behalf.

sign and date

Emergency Contact Address (Must Speak English)

Name of Emergency Contact E-Mail Address

Emergency Contact’s Mailing Address

City Postal Code Country

Emergency Contact’s Telephone/Mobile Number Emergency Contact’s Relationship to You

Parent Information

Father’s Name and Occupation Mother’s Maiden Name

Telephone/Mobile Number E-Mail Address

City Country
Please answer the following questions in no more than two sentences.

1. What is the most rewarding experience you have had?

2. What are your 3 best characteristics?

3. Do you have any family or friends in the U.S.? Please give details.

4. Please name friends or relatives that have participated on this program previously.

5. What are three words that you think of when you think about the United States?

6. What two things would you change about yourself?

Please answer the following questions briefly.

How many brothers and sisters do you have? Have you ever had a teacher from the United States?

Have you ever volunteered your time? Explain.

Do you enjoy spending time in large groups?

Please answer each of the following.

1. What would you do if you had promised to stay at a job for four months but found another job that paid better money? Explain.

2. What type of job placement would make you happiest? (Please mention location, size and atmosphere.)

3. How would you resolve a conflict with your employer?

4. Describe in detail one of the most exciting or adventurous travel experiences you have had.
InterExchange Work & Travel USA Program Agreement

Please read the following carefully and be sure you understand all the points. This is a legal and binding agreement that shall constitute part of your agreement with Work &
Travel USA/InterExchange.

• I agree that I will perform my duties to the best of my ability and indemnify,
without limitation, InterExchange, its directors, officers, employees, agents and
• I will cooperate fully with those supervising the program on behalf of and in
cooperation with InterExchange, and I agree to abide by any reasonable instructions
organizations affiliated with it, against any loss or damage suffered by any of them, that they may give me.
or any claims made against any of them as a result of any breach or negligence by
me during my participation in the program.
• I hereby agree that InterExchange, Inc., its officers, employees, affiliates and
agents may, without liability, or expense to themselves, take whatever action they
• I will attend all orientation sessions in my home country and the city of arrival
in the U.S.
deem appropriate with regard to my health and safety and may place me in a
hospital or health-related facility for medical services and treatment or, if no hospital
• I will carry out the duties and responsibilities of the position of which InterExchange
has arranged for me. I acknowledge that InterExchange is primarily a cultural
or health-related facility is readily available, may place me in the hands of a local
medical doctor or health provider for treatment or service.
exchange organization rather than an employment agency and only facilitates the
arrangements between my employer and me and that any employment relationship
• I am between the ages of 18 and 28 and a full-time student at a tertiary level
of education.
is solely between my employer and me. This employment is temporary and runs
for the duration of my work authorization documents (J-1 visa and DS-2019 form).
• I will be covered by health and accident insurance for the length of my stay in
the U.S.
I understand that if my work is not satisfactory to my employer, he/she holds the
right to fire me. I agree to work the entire period as stated on the work agreement
• I will obtain a valid passport and comply with all vaccinations and immunization
requirements.
letter. Not working through the period that I have indicated constitutes a violation of • I will complete all visa requirements in accordance with instructions.
my agreement with my employer and may lead to my visa being cancelled and my • I will obey all U.S. federal, state and local laws.
termination from the program. In addition, I will not accept any form of employment
other than what is permitted by the work authorization documents.
• I understand and agree that any controversy, dispute or claim arising out of, or in
connection with this agreement, the relationship of the parties, or its interpretation,
• I understand that taking a second job is allowed as long as it does not interfere
with the duties and responsibilities of my primary place of employment.
performance or non-performance, or any breach thereof shall be determined solely
in arbitration conducted in New York City in accordance with the then existing rules
• I will not terminate my contract with my employer without the approval of the of the American Arbitration Association.
employer and an InterExchange Program Coordinator. • I agree to register in SEVIS within 10 days of my arrival to the United States.
• After fulfilling my contract with my employer, I will return to my home country
within 30 days of the expiration date of the DS-2019 form.

I, the undersigned, an applicant to be a participant in the Work & Travel USA program sponsored by InterExchange Inc., agree to the terms and conditions set forth in this
application and agreement.

Personal Declaration:
I confirm that I have read and understand the application and agreement and that the information I have provided is true, complete and accurate.

Applicant’s Signature Date Parent or Guardian’s Signature (if applicant is under the age of 21) Date

Print Name Parent or Guardian’s Printed Name

Application Checklist:
Please make sure you send all of the following items to your Work & Travel Program/InterExchange representative. An interview cannot be arranged until all the
necessary documents are provided.

Completed Application Form Driver’s License (If Applicable) Resume/Curriculum Vitae (If Applicable)
Proof of Student Status Two References Personal Essay (If Applicable)
Copy of Passport Lifeguarding Certificate (If Applicable)

Please remember to sign the application in the Personal Declaration above.