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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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