DEPARTMENT OF HEALTH AND HUMAN SERVICES O.M.B. NO. 0990-0001
WASHINGTON, D.C.
APPLICATION FOR WAIVER OF THE TWO-YEAR FOREIGN
RESIDENCE REQUIREMENT OF THE EXCHANGE VISITOR PROGRAM
Supplement A – Research Supplement B – Clinical Care
SECTION 1. APPLYING INSTITUTION AND PROGRAM
1. NAME OF INSTITUTION 2. TELEPHONE, AREA & NUMBER
3. COMPLETE ADDRESS
4. NAME AND POST OF RESPONSIBLE ADMINISTRATIVE OFFICER WHO CERTIFIES THIS APPLICATION AND THE DATA IT CONTAINS
5. PROGRAM (Department or Division) IN WHICH EXCHANGE VISITOR IS ENGAGED
MEDICAL DIRECTOR (Supplement B) 6. PRINCIPAL PROGRAM OFFICER, RANK AND POSITION (Supplement A)
7. SOURCE OF PROGRAM FUNDS (Supplement A ONLY) - If supported by HHS or other public funds, identify grants by source, title, number and amount and terminal dates.
SECTION 2. RELATION OF EXCHANGE VISITOR TO INSTITUTION AND PROGRAM
8. PRESENT POSITION CLASSIFICATION AND SALARY
(1) HOW LONG HAS THIS PERSON BEEN EMPLOYED IN THE INSTITUTION? (Supplement A ONLY) (2) IN THE PROGRAM?
(3) WHAT EFFORTS HAVE BEEN MADE TO REPLACE THIS INDIVIDUAL? (4) AT WHAT SALARY? (5) WITH WHAT RESULTS?
SECTION 3. EXCHANGE VISITOR FOR WHOM WAIVER IS REQUESTED
9. NAME (Surname) (Given names) (Maiden name, if married female)
10. RESIDENTIAL ADDRESS (No., Street, City, State or Province, Country)
11. CURRENT ADDRESS OF SPOUSE, IF DIFFERENT
12. OCCUPATION TITLE
13. DATE OF BIRTH (Month, Day, Year) 14. BIRTHPLACE (City, State, Country)
15. SEX: 16. MARITAL STATUS:
MALE FEMALE MARRIED SINGLE
17. CITIZENSHIP 18. COUNTRY OF LAST RESIDENCE BEFORE 19. IF NO LONGER IN U.S.A., STATE LAST PLACE
ENTERING U.S.A. OF U.S. RESIDENCE (City & State)
20. ALIEN REGISTRATION NO.
21. LOCAL IMMIGRATION OFFICE 22. DATE OF ENTRY INTO U.S.A. AS 23. EXPIRATION DATE OF CURRENT PERMIT (I-94)
WHERE REGISTERED EXCHANGE VISITOR
24. WHAT FUNDS WERE USED TO FINANCE THE EXCHANGE VISIT?
U.S. GOV’T U.N. OR AFFILIATE PRIVATE AGENCY VISITORS GOV’T OTHER
(If government agency, please identify)
FORM HHS 426
(REV. 03/03)
