Fillable Delta Regional Authority J-1 Visa Waiver Program (Delta Regional Authority)

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Delta Regional Authority J-1 Visa Waiver Program (Delta Regional Authority)

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Delta Doctors Program – Affidavit and Agreement
Effective: September 4, 2020
Delta Regional Authority
J-1 Visa Waiver Program
Affidavit and Agreement
I, ______________________________, being duly sworn, hereby request the Delta
Regional Authority (DRA) to review my application for the purpose of recommending a
waiver of the foreign residency requirement set forth in my J-1 Visa, pursuant to the terms
and conditions as follows:
1. I understand and acknowledge that the review of this request is discretionary and that in
the event a decision is made not to grant my request, I hold harmless DRA, the Federal Co-
Chairman, any and all DRA employees and representatives from any action or lack of
action made in connection to this request.
2. I further understand and acknowledge that the entire basis for the consideration of my
request is DRA’s desire to improve the availability of primary and specialty medical care
in areas designated by the Secretary of the U.S. Department of Health and Human Services
as a Health Professional Shortage Area (HPSA), Mental Health Professional Shortage Area
(MHPSA), Medically Underserved Area (MUA), or Medically Underserved Population
(MUP) within DRA’s congressionally-mandated footprint. I understand DRA only
provides J-1 visa waiver recommendations for physicians practicing at work sites located
within DRA’s congressionally-designated footprint, and I agree to practice therein.
Furthermore, I understand the sponsorship of any waiver by DRA is strictly voluntarily.
3. I understand and agree that in consideration for a waiver, which eventually may or may not
be granted, I shall render primary or specialty medical care services to patients, including
the indigent, for a minimum of forty (40) hours per week, or 160 hours per month, within
a designated HPSA, MUA, MHPSA, or MUP located within DRA’s congressionally-
mandated footprint. Unless there are extenuating circumstances which DRA approves,
such service shall commence no later than 90 days after I receive approval by USCIS of
my waiver request and shall continue for a minimum of three years or longer in accordance
with the employment contract.
4. I understand and acknowledge that DRA does not provide letters of support or no objection
for any instances of change in employment status. DRA cannot and does not determine
extenuating circumstances.
Delta Doctors Program – Affidavit and Agreement
Effective: September 4, 2020
5. I agree to incorporate all the terms of this “J-1 Visa Waiver Affidavit and Agreement” into
any and all employment agreements I enter pursuant to paragraph 3 and to include in each
such agreement DRA’s liquidated damages clause, which is attached hereto, payable to the
employer (a copy of all employment agreements are attached to this request). This damages
clause shall be activated by my termination of employment, initiated by my employer for
cause or by me for any reason, only if my termination occurs before fulfilling the minimum
three-year service requirement. In the event of a transfer under DRA’s liquidated damages
clause, a transfer notification form must be obtained by DRA. I will ensure that this form
is completed and returned to DRA with a copy to the State Contact.
6. I further agree that any employment agreement I enter pursuant to paragraph 3 shall not
contain any provision, which modifies or amends any of the terms of this “J-1 Visa Waiver
Affidavit and Agreement.”
7. I understand and agree that I will provide health services to individuals without
discriminating against them because: (a) they are unable to pay for those services or (b)
payment for those health services will be made under Medicare or Medicaid.
8. I have read, signed, and fully understand the “DRA J-1 Visa Waiver Program Guidelines”,
a copy of which is attached to this request.
9. I expressly understand this waiver of my foreign residence requirement must ultimately be
approved by the USCIS, and I agree to provide placement notification of the specific
location and nature of my practice to DRA when I commence rendering services within
DRA’s congressionally-mandated footprint.
10. I declare and certify, under penalty of the provisions of 18 U.S.C. 1101, that I do not have
pending nor am I submitting during the pendency of this request, another request to any
United States Government department or agency or any State Department of Public Health,
or equivalent, other than DRA to act on my behalf in any matter relating to a waiver of my
two-year home-country physical presence requirement.
11. I understand and acknowledge that if I willfully fail to comply with the terms of this “J-1
Visa Waiver Affidavit and Agreement,” DRA’s Office of the Federal Co-Chairman will
notify the USCIS that I am out of compliance. Additionally, any and all other measures
available to the Office of the Federal Co-Chairman will be executed in the event of my
non-compliance.
LIQUIDATED DAMAGES CLAUSE
Any breach or non-fulfillment of conditions will be considered a substantial breach of this
agreement by you. If there is such a breach ________________________________________
(Employer) may, at its option, terminate this agreement immediately. In addition, it is agreed that
____________________________________ (Employer) will be substantially damaged by your
failure to remain at _____________________________________ (Employer/Facility Name) in
the practice of medicine for a minimum of three years and that, considering that precise damaged
are difficult to calculate, you will agree to pay _________________________________
(Employer) the sum of $250,000.00 if you fail to fulfill any portion of your minimum three-year
contract. Should you perform any portion of the employment contract, you agree to pay a pro rata
share based upon the number of months you failed to fulfill (i.e. $6,945.00 per month). In addition
to liquidated damages, ________________________________ (Employer) will recover from you
any other consequential damages, and reasonable attorney fees costs and expenses, due to the
failure to provide services to ____________________________________ (Employer) for a
minimum of three years, EXCEPT THAT, the full-time practice of medicine at another licensed
medical facility, in Health Professional Shortage area (as defined by the United States Public
Health Service) with the Delta Regional Authority (as defined by DRA) shall be considered the
same a fulltime practice of medicine at _______________________________________
(Employer) for purpose of this paragraph. In the event of a dispute under this paragraph, either
party may submit this matter to binding arbitration.
The parties agree in consideration of compliance with the forgoing, to indemnify and hold harmless
the Delta Regional Authority and / or any person, firm or corporation now or hereafter acting as
agent for the DRA in any capacity, and any successors in any such capacities and successors and
assigns of DRA, from and against any loss, claim, damage and expense in connection with, or
arising out of, compliance with the waiver application set forth herein or any other litigation.
Re: Additional Liquidated Damages Clauses
Any other clause mandating consequential or liquidated damages being paid to the employer must
be separate for the DRA clause. DRA takes no position with respect to the inclusion of such an
additional contractual agreement.
Delta Doctors Program – Affidavit and Agreement
Effective: September 4, 2020
Delta Doctors Program – Affidavit and Agreement
Effective: September 4, 2020
I declare under the penalties of perjury that the foregoing is true and correct.
Physician’s Signature: _________________________________________
Physician’s Name: ____________________________________________
Subscribed and sworn before me this ______ day of ______________________, 20_____.
__________________________________________ (Notary Public)
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Delta Regional Authority J-1 Visa Waiver Program (Delta Regional Authority)

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Completed 25 January 2021

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