Verification Form

Connecticut Conrad 30 / J-1 Visa Waiver Program
Verification Form
Physician
Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Employer
Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Facility Name
Facility Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
HPSA ID
By signing this form, I confirm that the J-1 Physician Physician Name , started full time employment at Emplolyer Name on Date which is within ninety (90) days of receiving approval from USCIS on Date .
____________________________________
Employer Signature
Date

MonthDayYear
____________________________________
Physician Signature
__________________
Date
Should be Empty: