J-1 Visa Waiver Affidavit and Agreement, Revised October 2018 Page 1 of 2

J-1 Visa Waiver Affidavit and Agreement

I, , being duly sworn, hereby request the Federal CoChair of the Appalachian Regional Commission to review my application for the purpose of 

recommending waiver of the foreign residency requirement set forth in my J-1 Visa, pursuant 

to the terms and conditions as follows:

1. I understand and acknowledge that the review of this request is discretionary

and that in the event a decision is made not to grant my request, I hold harmless the

Appalachian Regional Commission (ARC), the Federal Co-Chair, any and all ARC employees, 

agents and assigns from any action or lack of action made in connection with this request.

2. I further understand and acknowledge that the entire basis for the

consideration of my request is the ARC Federal Co-Chair’s voluntary policy and desire to 

improve the availability of primary medical care or specialty medicine in regions designated 

by the Health Resources and Services Administration (HRSA) as Health Professions Shortage 

Areas (HPSA) in Appalachia.

3. I understand and agree that in consideration for a waiver, which eventually may

or may not be granted, I shall render primary medical care or specialty medicine services to 

patients, including the indigent, for a minimum of forty (40) hours per week within a HRSA 

designated HPSA located in the ARC jurisdiction. Such service shall commence not later than 

90 days after I receive approval by the United States Citizenship and Immigration Services 

(USCIS) of my waiver request and shall continue for a minimum of three (3) years or longer, as 

a specific State policy may require. Any subsequent change in location must be reported 

immediately to ARC for concurrence.

4. I agree to incorporate all the terms of this J-1 Visa Waiver Affidavit and

Agreement into any and all employment agreements I enter pursuant to paragraph 3 and to 

include in each such agreement the ARC liquidated damages clause, of $250,000 payable to 

the employer. (A copy of all employment agreements are attached to this request) This 

damages clause shall be activated by my termination of employment, initiated by my 

employer for cause or by me for any reason, only if my termination occurs before fulfilling the 

minimum three year service requirement.

5. I further agree that any employment agreement I enter pursuant to paragraph

3 shall not contain any provision, which modifies or amends any of the terms of this J-1 Visa 

Waiver Affidavit and Agreement.

6. I also agree to incorporate all terms of this J-1 Visa Waiver Affidavit and

Agreement into any employment agreement I enter pursuant to paragraph 3.

7. I understand and agree that I will provide health services to individuals without

discriminating against them because (a) they are unable to pay for those services or (b) 

payment for those health services will be made under Medicare or Medicaid.
J-1 Visa Waiver Affidavit and Agreement, Revised October 2018 Page 2 of 2

8. I have read and fully understand the “ARC Federal Co-Chair’s J-1 Visa Waiver

Policy,” a copy of which is attached to this request.

9. I expressly understand that this waiver of my foreign residence requirement

must ultimately be approved by the USCIS, and I agree to provide written notification of the 

specific location and nature of my practice to the ARC and the State contact at the time I 

receive notification from USCIS and I commence rendering services in the ARC jurisdiction.

10. I declare and certify, under penalty of the provisions of 18 U.S.C. 1001, that I do

not have pending nor am I submitting during the pendency of this request, another request 

to any United States Government department or agency or any State Department of Public 

Health, or equivalent, other than the Appalachian Regional Commission to act on my behalf 

in any matter relating to a waiver of my two-year home-country physical presence 

requirement.

11. I understand and acknowledge that if I willfully fail to comply with the terms of

this J-1 Visa Waiver Affidavit and Agreement, the Office of the ARC Federal Co-Chair will notify 

the USCIS. Additionally, any and all other measures available to the Office of the ARC Federal 

Co-Chair will be taken in the event of my non-compliance.

I declare under the penalties of perjury that the foregoing is true and correct.

____________________________________________

Signature

Subscribed and sworn before me this day of , 20 .

(Notary Public)

ARC J-1 Visa Waiver Affidavit and Agreement 

Revised: October 2018