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

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J-1 Visa Waiver Program Completion Request Form (Delta Regional Authority)

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The J-1 Visa Waiver Program Completion Request Form (Delta Regional Authority) form is 3 pages long and contains:

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  • 63 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Delta Regional Authority

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DRA J-1 Visa Waiver Program - Completion Request Form
Effective: September 4, 2020
J-1 Visa Waiver Program
Completion Request Form
Physician’s Name:________________________________________________________
Current Home Address:
Street:______________________________________________________
City: ___________________ State:___________ Zip Code:_________
Home Phone: ________________________________________________
Email Address: _______________________________________________
Employer’s Name: ________________________________________________________
Street:_______________________________________________________
City: ___________________ State:___________ Zip Code:__________
Phone: ______________________________________________________
Email Address: _______________________________________________
Point of Contact: ______________________________________________
Worksite(s): Please list additional worksites on Page 3:
Name: ______________________________________________________
Street: ______________________________________________________
City: ___________________ State:___________ Zip Code:__________
County: _______________________________
HPSA: _________________________________________ MUA: ______
Dates of Employment:________________ to ________________
Date of Completion: ____________________________________
DRA J-1 Visa Waiver Program - Completion Request Form
Effective: September 4, 2020
I HEREBY CERTIFY THAT I, _____________________________________________,
PROVIDED DIRECT PATIENT CARE AT THE WORKSITE(S) LISTED FOR FORTY
(40) HOURS PER WEEK, OR ONE HUNDRED SIXTY (160) HOURS PER MONTH,
FOR THREE (3) YEARS.
Physician’s Signature: ___________________________________
Date: _________________________________________________
I HEREBY CERTFIY THAT DOCTOR ____________________________________
PROVIDED DIRECT PARTIENT CARE AT THE WORKSITE(S) LISTED FOR
FORTY (40) HOURS PER WEEK, OR ONE HUNDRED SIXTY (160) HOURS PER
MONTH, FOR THREE (3) YEARS.
Employer’s Signature: ___________________________________
Date: _________________________________________________
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DRA J-1 Visa Waiver Program - Completion Request Form
Effective: September 4, 2020
ADDITIONAL WORKSITES
Name: ______________________________________________________
Street: ______________________________________________________
City: ___________________ State:___________ Zip Code:__________
County: _______________________________
HPSA: _________________________________________ MUA: ______
Dates of Employment:________________ to ________________
Date of Completion: ____________________________________
Name: ______________________________________________________
Street: ______________________________________________________
City: ___________________ State:___________ Zip Code:__________
County: _______________________________
HPSA: _________________________________________ MUA: ______
Dates of Employment:________________ to ________________
Date of Completion: ____________________________________
Name: ______________________________________________________
Street: ______________________________________________________
City: ___________________ State:___________ Zip Code:__________
County: _______________________________
HPSA: _________________________________________ MUA: ______
Dates of Employment:________________ to ________________
Date of Completion: ____________________________________
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J-1 Visa Waiver Program Completion Request Form (Delta Regional Authority)

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Completed 25 January 2021

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