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State:

Worker’s Comp Provider:

WC Policy #:

TaxID/EIN:
Website:

national students do you intend to hire?:
Worksite address
(if different from above)

State:

Offer made to
Dates of employment: From

To
Manager’s name:

Manager’s phone:
s email:

Off season phone:
Student job title:

W
age per hour:

verage number of hours per week:
Is an end of season bonus available?

Yes



Yes


ype of housing

Estimated cost of utilities:
Housing deposit:

Is housing furnished?:
How many people share house?:

e room?:
By signing below I am contracting with CIEE to arrange employment of students from abroad through the J-1 Summer Work/Travel program. I am an authorized representative of the company named
above and my signature on this agreement constitutes agreement by the company. I acknowledge the aims and objectives of the CIEE Work & Travel USA program as a U.S. Department of State
authorized Exchange Visitor Program, with the purpose of providing cultural exchange opportunities to qualied foreign students, and advancing the public diplomacy goals of the United States. I will
adhere to all applicable regulatory provisions that govern this program, and all CIEE policies. I understand that participants may undertake a period of employment of no more than four months during
their college/university vacation period. The job I am offering is seasonal/temporary in nature and will not displace year-round positions for American workers. I understand that I am not permitted to
employ J-1 Summer Work Travel participants if I have experienced layoffs within 120 days of the participant’s employment, and/or if I currently have workers on lockout or on strike. I agree to notify

Signature:

Date

Atlas ID:
address:

CIEE Representative:

Country of residence:

4

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