Fillable U.S. Department of State Exchange Visitor Attestation (Delta Regional Authority)

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U.S. Department of State Exchange Visitor Attestation (Delta Regional Authority)

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The U.S. Department of State Exchange Visitor Attestation (Delta Regional Authority) form is 1 page long and contains:

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  • 6 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Delta Regional Authority

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Delta Doctors Program – Physician Attestation Form
Effective: September 4, 2020
U.S. Department of State
Exchange Visitor Attestation
I, ________________________________________, hereby declare and certify, under penalty of
the provisions of 18 U.S.C. 1001, that I do not now have pending, nor am I submitting during the
pendency of this request, another request to any U.S. Government department or agency or any
other State Department of Public Health, or any equivalent, other than the Delta Regional
Authority, to act on my behalf in any matter relating to a waiver of my two-year home-country
physical-presence requirement.
__________________________________________ _____________________
Signature Date
Subscribed and sworn to before me This _________________________ day of _______, 20___.
__________________________________________
Notary Public
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U.S. Department of State Exchange Visitor Attestation (Delta Regional Authority)

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Completed 25 January 2021

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