Annual Revenue
TRAINING/INTERNSHIP PLACEMENT PLAN
Trainee/Intern Name (Family Name, First Name, Middle Name)
SECTION 1: PARTICIPANT INFORMATION
U.S. Department of State
E-mail Address
Select One: Current Field of Study or Profession If Professional, Number of Years Experience in Field
Type of Degree or Certificate Date Awarded (mm-dd-yyyy) or Expected Training/Internship Dates (mm-dd-yyyy)
From To
SECTION 2: SITE OF ACTIVITY INFORMATION
Name of Supervisor (Last, First, MI) Title
E-mail Address Telephone Number
Host Organization Name Street Address of Training/Internship Site Suite
City State ZIP Code Website
Employer ID Number (EIN) Hours Per Week Will Trainee/Intern receive a stipend?
Yes No If Yes, how much?
per
*OMB APPROVAL NO. 1405-0170
EXPIRATION DATE: 12-31-2014
ESTIMATED BURDEN: 1.5 hours
Does your organization have a Worker's Compensation (WC) policy?
Yes No If so, Name of Carrier
Will your WC Policy cover the intern/trainee?
Yes No
Number of Full-Time Employees
$0 to $3 Million $3 Million to $10 Million $10 Million to $25 Million $25 Million or More
Supervisor - I certify the following:
1. I hereby acknowledge that I have reviewed, understand, and will follow this Training/Internship Placement Plan (T/IPP).
2. I will adhere to all applicable regulatory provisions that govern this program (22 CFR Part 62).
3. That Trainees and Interns will not displace full- or part-time, seasonal or permanent American workers, or serve to fill a labor need.
4. I will conduct the required periodic evaluations of this trainee/intern.
5. I will notify the designated Sponsor contact regarding any concerns about, changes in, or deviations from the T/IPP at the earliest available
opportunity, to include, but not limited to, changes of Supervisor or Host Organization, or changes in rotational assignments.
6. I will notify the Sponsor in the event of an emergency involving a Trainee or Intern, as well as any information that I receive about the Trainee or
Intern that might represent a possible threat to their safety, security, welfare, or general well-being.
7. I will notify the Sponsor in the event I receive any information regarding the Trainee or Intern that might be a cause of embarrassment or disgrace
to the Department of State or the Exchange Visitor Program, to include, but not limited to, arrest, or engagement in illegal or immoral activities.
8. That I am participating in this Exchange Visitor Program in order to provide the above listed individual with training or an internship as delineated in
the T/IPP, and not to simply to engage this individual in labor.
9. I understand that any on-the-job training or internship that the Trainee or Intern participates in meets all of the requirements of the Fair Labor
Standards Act, as amended (29 U.S.C. § 201 et seq.).
DS-7002
01-2013
Page 1 of 4
Printed Name of Trainee/Intern Date (mm-dd-yyyy)
Signature of Trainee/Intern
SECTION 3: CONTRACT AGREEMENT
Trainee/Intern - I certify the following:
1. I hereby acknowledge that I have reviewed, understand, and will follow this Training/Internship Placement Plan (T/IPP);
2. That I am entering into this Exchange Visitor Program in order to participate as a Trainee or Intern as delineated in the T/IPP, and not to simply
engage in labor or work in the United States.
3. That I will contact the U.S. Department of State's Bureau of Educational and Cultural Affairs (ECA) at the earliest possible opportunity if I believe
that my Sponsor or Supervisor is not providing me with a legitimate internship or training, as delineated on my T/IPP.
4. I understand that any attempt to falsify, conceal, or cover up by any trick, scheme, or device a material fact by making any materially false,
fictitious, or fraudulent statement or representation; or making or using any false writing or document, knowing the same to contain any materially
false, fictitious, or fraudulent statement or entry is punishable by fine or imprisonment of up to 5 years under Title 18 U.S.C. § 1001.
