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Work & Travel USA

Name of CIEE Representative: Interviewed by (name): Date (day/month/year):

Country: Representative Code:

Application Winter 2012 / 2013
Please fill in form using all caPital letters.

Departure and Return Dates
arrival date in u.s. (DD/MM/YYYY): 14/12/2012 Ds-2019 start date (DD/MM/YYYY): 16/12/2012 Ds-2019 end date (DD/MM/YYYY): 20/03/2013 Date of departure fromu.s. (DD/MM/YYYY): 21/03/2013
Can be no more than five days prior to DS-2019 start date. Date you want to be eligible to work in the U.S. Last day you want to be eligible to work in the U.S. Can be no more than four months after DS-2019 start date. Can be no more than 30 days after DS-2019 end date and no more than five months after arrival date.

Personal Details
last name: first name: gender:city of Birth:

exactly as they appear on your passport. Please include a copy of your passport’s iD page with your application.

RUEDA CORTEZ ANDRE
 female  male Date of Birth (DD/MM/YYYY): 28/04/1991 country of Birth: PERU country of study: PERU

middle name: RICARDO

LIMA

country of citizenship: PERU country of legal residence: PERU Passport number: 5702423 Passport expirationDate (DD/MM/YYYY): 08/06/2017

Contact Information
Postal code: email (Mandatory):

Permanent Home address

Home mailing address: JR, MASCAYPACHA 142, INDEPENDENCIA city: LIMA country: LIMA mobile number: 511981080429 Phone number (Country code - City code - Number): 5117807246

Emergency Contact
last name: CORTEZ PORTELLA relationship to Participant: MOTHER address: JR. MASCAYPACHA 142,INDEPENDENCIA Postal code: email: city: LIMA country: LIMA mobile number: 511998184939 Phone number (Country code - City code - Number): 5117807246 first name: JULIA ANDREA

Previous Visas if you have previously received more than one J-1 Visa, please use an additional sheet of paper to provide the same information as below for each one.
Have you ever received a J-1 visa to enter the usa?: nameof Program: INTEJ name of sponsoring organization: INTEJ Dates of Previous Ds-2019 form: from (DD/MM/YYYY):  Yes  no if yes, how many?: Program number: city: LIMA to (DD/MM/YYYY): state: if yes, please complete the following for each previous J-1 visa:

Other Visa Information
Have you ever been denied entry into the u.s.? Have you ever applied for a visa to emigrate permanently to the u.s.?Have you ever been refused a visa by a u.s. embassy? Have you ever been arrested and convicted of a crime in your home country? Have you ever been arrested and convicted of a crime in the u.s.? *if you answered Yes to any of these questions, please contact your ciee representative.
www.ciee.org/wat Work & Travel USA
Last updated 2012.06.01

 Yes*  no  Yes*  no  Yes*  no  Yes*  no  Yes* no

Work & Travel USA
University/College

Name of CIEE Representative: Interviewed by (name): Date (day/month/year):

Country: Representative Code:

Application Winter 2012 / 2013

Name of Institution (e.g. university, polytechnic): UNIVERSIDAD City: LIMA Major Field of Study: INTERNATIONAL

NACIONAL MAYOR DE SAN MARCOS

BUSSINES

What is the course length of your major field ofstudy (in years)?: How many full semesters of university study have you already completed?: How many years of university study will you have completed by the time of your departure to the U.S.?: Will you be a full-time university student at the time you leave to the U.S.?: Will you be a full-time university student when you return to your country of residence?:

Proof of Student Status Thissection must be completed by an official from your educational institution. If your educational institution will not sign this form you must attach an official letter on university letterhead verifying this same information.
Option A: Student Not in Final Year of Study  I certify that the named student has, as of this date, successfully completed at least one semester (or equivalent) of...
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