EIRAS INTERNATIONAL LIMITED

SHOP 4 VILLAGE PLAZA

24 CONSTANT SPRING ROAD
KINGSTON 10
TEL: 8766499300

SUMMER WORK AND TRAVEL APPLICATION (2017/2018)

Application Type*

First Name*

Middle Name

Family Name*

Gender*

Email Address*

Confirm Email Address*

Family
Name_______________________________________________________________________________

First
Name*______________________________________________________________________________

Middle Name__________________________________________________________________

Gender* ____________________________________________

Date of Birth*____________________________________________

Place of Birth*___________________________________________
Country of Birth*____________________________________________________________________

Country of Legal Permanent Residence*_________________________________________________

Country of Citizenship*________________________________________________________________

Mailing Address*_____________________________________________________________________

City* _____________________________________________

Country*_____________________________________________________

Zip Code_________________________________________________

Telephone Number__________________________________________

Email Address*______________________________________________________________________

Skype ID____________________________________________________

Year of study in university/college________________________________

University Name_______________________________________________

Emergency Contact Name*___________________________________________

Emergency Telephone Number*_______________________________________________________

Emergency Email Address________________________________________________________

Have you ever been issued a USA Visa? If yes, please provide:

a) Visa issue date________________________ B) Visa expiry date______________

DATES OF OFFICIAL VACATION

Start
Date*_______________________________________________________________________________
_

End Date*___________________________________________________________________________

PROGRAM INFORMATION_____________________________________________________

Start Date*___________________________________________________________________________

End Date*___________________________________________________________________________

PROGRAM OPTION
Program Option*

CSB-Placement Self-Placement Walk-In

Number of previous participations in the program*________________________________________

Name of Sponsor_______________________________________________________________________

Social Security Number__________________________________________________________

I confirm that the information given above is true to the best of my knowledge. I am also aware that
false information provides by me will result in immediate cancellation of my application from the J1
Summer Work and Travel program.

Name__________________________________Sign______________________________Date_________

This document MUST be printed and physically signed by the applicant.