Request for a DPH Letter of Support to include in HHS J-1 Visa Waiver Application

Form DPH-J1CCW
Request for a DPH Letter of Support to include in HHS J-1 Visa Waiver Application
Physician's Information
Name

First NameLast Name
CT License Number:
License expiration date:

MonthDayYear
Email
example@example.com
Primary Care Practice Type:
If applicable, please list the addresses of any additional parties you request the support letter be mailed to.
Employer Information
Employer Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
On the employment contract - Employment Commitment START date:

MonthDayYear
On the employment contract - Employment Commitment END date:

MonthDayYear

Primary Practice Facility

Additional Information

The following information is for internal DPH use only for affirmative action and health access planning purposes. This information is not a requirement to receive a state attestation letter.
Board Certifications (if any):
Language(s) spoken other than English:
Country of Origin:
Any country where you have resided for more than three months, since 1990:
Assurances
I hereby acknowledge that all information and statements contained herein are true and do not misrepresent fact. I further acknowledge that I have not evaded or suppressed any information contained in this application or in any of the supporting materials.

Physician Signature
Physician Printed Name
Date

MonthDayYear
This form and accompanying documents may be submitted electronically to:
dph-pco@ct.gov
Subject: HHS Support Letter Request

Or by mail to:
Primary Care Office ATTN: NIW
CT Department of Public Health
410 Capitol Ave. MS # MAT 108
Hartford, CT 06134
Should be Empty:

Physician's Information