DRA J-1 Visa Waiver Program - Completion Request Form

Effective: September 4, 2020 

J-1 Visa Waiver Program

Completion Request Form 

Physician’s Name:________________________________________________________ 

Current Home Address: 

Street:______________________________________________________ 

City: ___________________ State:___________ Zip Code:_________ 

Home Phone: ________________________________________________ 

Email Address: _______________________________________________ 

Employer’s Name: ________________________________________________________ 

Street:_______________________________________________________ 

City: ___________________ State:___________ Zip Code:__________ 

Phone: ______________________________________________________ 

Email Address: _______________________________________________ 

Point of Contact: ______________________________________________ 

Worksite(s): Please list additional worksites on Page 3: 

Name: ______________________________________________________ 

Street: ______________________________________________________ 

City: ___________________ State:___________ Zip Code:__________ 

County: _______________________________ 

HPSA: _________________________________________ MUA: ______ 

Dates of Employment:________________ to ________________ 

Date of Completion: ____________________________________ 
DRA J-1 Visa Waiver Program - Completion Request Form

Effective: September 4, 2020 

I HEREBY CERTIFY THAT I, _____________________________________________, 

PROVIDED DIRECT PATIENT CARE AT THE WORKSITE(S) LISTED FOR FORTY 

(40) HOURS PER WEEK, OR ONE HUNDRED SIXTY (160) HOURS PER MONTH, 

FOR THREE (3) YEARS.

Physician’s Signature: ___________________________________

Date: _________________________________________________ 

I HEREBY CERTFIY THAT DOCTOR ____________________________________ 

PROVIDED DIRECT PARTIENT CARE AT THE WORKSITE(S) LISTED FOR 

FORTY (40) HOURS PER WEEK, OR ONE HUNDRED SIXTY (160) HOURS PER 

MONTH, FOR THREE (3) YEARS.

Employer’s Signature: ___________________________________

Date: _________________________________________________ 
DRA J-1 Visa Waiver Program - Completion Request Form

Effective: September 4, 2020 

ADDITIONAL WORKSITES

Name: ______________________________________________________ 

Street: ______________________________________________________ 

City: ___________________ State:___________ Zip Code:__________ 

County: _______________________________ 

HPSA: _________________________________________ MUA: ______ 

Dates of Employment:________________ to ________________ 

Date of Completion: ____________________________________ 

Name: ______________________________________________________ 

Street: ______________________________________________________ 

City: ___________________ State:___________ Zip Code:__________ 

County: _______________________________ 

HPSA: _________________________________________ MUA: ______ 

Dates of Employment:________________ to ________________ 

Date of Completion: ____________________________________ 

Name: ______________________________________________________ 

Street: ______________________________________________________ 

City: ___________________ State:___________ Zip Code:__________ 

County: _______________________________ 

HPSA: _________________________________________ MUA: ______ 

Dates of Employment:________________ to ________________ 

Date of Completion: ____________________________________