J-1 V
isa Waiver Program
Physician Employment Verification Form
Ø This form is not to be submitted with the waiver application, but is to be completed
and mailed to the DRA within the physician’s first week of practice.
Ø Include copies of the physician’s state medical license with this form if they were not
included / available at the time the J-1 Waiver Application was submitted. Also
include copies of I-94 renewals and approval notices with this document.
Ø If the physician will be providing services for the employer at different sites than the
office site listed below, please provide those addresses on a separate page and attach
to this form.
PHYSICIAN:
Name: (print or type)______________________________ Employment Start Date:_____________
I-612 Approval Date: ____________________ H-1(b) Approval Date: ____________________
Address: Home: ______________________________ Office: ___________________________
Street Street
______________________________ ___________________________
City/State/Zip City/State/Zip
______________________________ ___________________________
Home Phone Work Phone
Physician’s E-mail Address: _____________
__________________________________________
I hereby certify that I, the undersigned, do provide primary health care services at the above stated address
for a minimum of 40 hours per week or 160 hours per month.
Physician’s Signature_______________________________________ Date:_________________
DRA J-1 Visa Waiver Program – Physician Employment Verification Form
Effective: September 4, 2020
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