DS2019ApplicationCHECKLIST

PleasecompleteandincludedwitheachapplicationsubmittedtoJanusInternational
DS2019cannotbeissuedwithoutthisdocument

Mongolia
Country:____________________

MNAEYE
Agency:_______________________________________

BATBAYAR
LastName:_

UYANGA
FirstName:

07/11/1991
uyanga_lilo@yahoo.com
(MM/DD/YYYY)___________
ParticipantsEmail:______________________________DateofBirth

CountryofBirth:UB/MONGOLIA

Middle:

__CountryofCitizenship:Mongolia

_____________

ProgramStartDate:_______________________ProgramEndDate:______________________
NameofEmployer:_______________________________________________________________

ParticipantsJobTitle:____________________________________________________________

NAVY PIER, CHICACO, ILLINOIS

AddressofEmployer:_____________________________________________________________
HousingAddress:_________________________________________________________________

RequiredDocuments
(__)

PersonalDataInformation

(__)

CriminalBackgroundCheckwithEnglishtranslation(onlyifrequiredbyemployer)

(__)

Photocopyofpassportshouldnotexpireatleast6monthsbeforetheprogramstartdate

(__)

MedicalInformationshouldbephysicallyfittoparticipateintheWorkandTravelProgram

(__)

EducationalBackgroundandProofofStudentStatus

(__)

WorkandTravelProgramApplicationandsignedProgramTerms

(__)

ReferenceInformation

(__)

InterviewConfirmationandEvaluation

(__)Orientationconfirmation
(__)
(__)

SignedJobOffer
FormDS7007(forSELFPLACEMENTApplications)
*ForSelfPlacedJobs,FullycompleteDS7007formmustbeincludedandsignedbytheapplicantand
theemployer.

Comment:

______________________________________________________________________________________________________
______________________________________________________________________________________________________
CompletedBy:
DateCompleted:

04/26/2012

Janus International Hospitality Student Exchange

Work and Travel Application

INTERNATIONAL HOSPITALITY STUDENT EXCHANGE

PLACE
PHOTO
HERE

Janus International Hospitality Student Exchange Office

16102 Theme Park Way
Doswell, Virginia 23047
Toll Free: 1-866-249-3888
Fax: 1-804-876-3113
E-mail: student@janus-international.com

Name of Representative: _______________________________________________________

PERSONAL DATA (Put information as it appears on passport)

BATBAYAR

UYANGA

Last Name

First Name

Middle Name

07/11/1991
Date of Birth (month/day/year): ______________________
Married

Single

Children: Yes

ULAANBAATAR
Place of Birth (City):__________________________

Female

Male
No

Mongolia
Country: _______________________________

MONGOLIA
Citizenship:_________________________________
MONGOLIA
Country of Permanent Legal Residency:______________________________________________________

*Please include a photocopy of Passport

PERMANENT ADDRESS
14,37TH APARTMENT,5TH KHOROOLOL, 3RD KHOROO,SUKHBAATAR DISTRICT
Number and Street Name
ULAANBAATAR

976

MONGOLIA

City

Postal Code

Country

+[976]-99147255

Telephone Number (including the country code and area code)

uyanga_lilo@yahoo.com
E-Mail Address of the Participant: __________________________________________________________

WORK AND TRAVEL SITE INFORMATION

MNAEYE
Name of Work and Travel Site: ____________________________________________________________
Time centre building, fourth floor, 210620 Baga Toiruu street, Ulaanbaatar, Mongolia
Address: ______________________________________________________________________________

Dates Availability (month/day/year)

05/27/2012
Start:___________________

09/10/2012
End:_________________

CONTACTS IN THE UNITED STATES

Do you have a family member, relative or close friend in the United States? Yes ___

No___

Number and Street Name

City

Postal Code

Telephone Number

EMERGENCY CONTACT INFORMATION

REGZEDSUREN

MOTHER

Name

Relationship

14,37TH APARTMENT,5TH KHOROOLOL, 3RD KHOROO,SUKHBAATAR DISTRICT

Address
ULAANBAATAR

MONGOLIA

976

City

Country

Postal Code

+[976]-99859560, +[976]-93046869

Telephone Number

EDUCATIONAL BACKGROUND
Are you currently enrolled as a student? Yes

No

Field of Study: ___________________________

Undergraduate Program

Graduate Program

*Please include Resume/CV and Introduction Letter

Work and Travel History
Have you ever participated in a Work and Travel Program in United States? Yes

No

If you answered Yes, please complete the following questions:

When did you participate in the Work and Travel Program (month/date/year)? _______________________
What is the name of the Host/Employer? ________________________ What State? __________________

PROOF OF STUDENT STATUS

*To be completed by the School Official
Student Name: _________________________________________________________________________
Name and Address of School: _____________________________________________________________
_____________________________________________________________________________________
Major Field of Study: ____________________________________________________________________
Student Participants Expected Date of Graduation (month/date/year): _____________________________
This is to certify that _________________________________ is currently registered as a full time student
in our school for this academic year.
Name of the School Official: ______________________________________________________________
Title: _________________________________________________________________________________
Signature: ____________________________________________________Date: ____________________

SCHOOL
SEAL

MEDICAL INFORMATION
*Must be completed by a Registered Physician in English
Patients Name: _________________________________________________________________________
Height: _____ in cm
Weight: _____ in kg
Blood Pressure:______ Pulse:_______
Please state the patients overall health: ______________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Has the patient been afflicted or is currently afflicted of the following? If so, please provide detailed
information regarding the patients affliction.
Yes
No
Yes
No
Chicken Pox
___
___
Seizure
___
___
Measles
___
___
Frequent Cough
___
___
Mumps
___
___
Appendectomy
___
___
Rheumatic Fever
___
___
Diabetes
___
___
Malaria
___
___
Severe Migraine
___
___
Hepatitis
___
___
Speech Defect
___
___
Goiter
___
___
Asthma
___
___
Allergies
___
___
Others
___
___
Has the patient been hospitalized for the past 5 years? Yes ___ No___
Is the patient currently taking injections or medications? Yes ___ No___
Has the patient been diagnosed with any illness or condition which requires regular medical attention? Yes
___ No___
Please provide detailed information about the patients affliction: _________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Does the patient have allergies? Yes ___ No___ If yes, what is the patient allergic to and what reactions is
the patient developing?: __________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Can these allergies be controlled by medications? Yes ___ No___
Please state any restrictions of the patient during physical activities: _______________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

*Medical Insurance provided by Janus International Student Exchange does not cover pre-existing
conditions. The participant has been made aware of any possible pre-existing conditions for which they
may need additional fees for the insurance coverage.
______________________________________________________________________________________
Physicians name and put signature above
Date
______________________________________________________________________________________
Place of Examination

REFERENCE INFORMATION
*To be completed by current or former employer, manager or teacher.
Applicants Name: ______________________________________________________________________
Name of Reference: _____________________________________________________________________
Title: ______________________________________ Telephone Number: __________________________
Relationship with the Applicant: ___________________________________________________________
How long have you known the applicant?:____________________________________________________
Do you think the applicant is qualified to participate in the Work and Travel Program? If yes, please justify
the answer._____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

INTERVIEW CONFIRMATION AND EVALUATION

*To be completed and signed by one of the following: Janus International Hospitality Student Exchange
Representative or Recruiting Organization Representative.
I have discussed the rules and regulati ons of the Work a nd T ravel Prog ram i n detail. I h ave al so
provided information about job openings and work sites available in this program.
By signing, I certify that I have inte
rviewed the par ticipant and reviewed the par ticipants
qualifications a nd ex perience. The pa rticipant has the required educa tion, sk ills and ex perience to
participate in the Work and Travel Program.
UYANGA
Participants Name: _____________________________________________________________________
Ganzorig Selengebaatar
Interviewers Name: _____________________________________________________________________
SWT program Manager
Interviewers Title: ______________________________________________________________________

Organization:
MNAEYE
___________________________________________________________________________
04/26/2012
Date and Place of Interview: _______________________________________________________________
English level assessment test, face to face speaking test
Method of Interview: ____________________________________________________________________

Comments or assessment to the participant: ___________________________________________________

Good at spoken English and prospective student. I talked with that student about 20 minutes.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Signature of the Interviewer:_______________________________________________________________

JANUS INTERNATIONAL HOSPITALITY STUDENT EXCHANGE

Agreement Terms for the Work and Travel Program
To complete your application, please take the time to carefully read these terms and guidelines. If you
agree to the conditions and statements outlined below, please put a check mark next to each item, then sign
and date the bottom of this page before submitting. Ask questions if you do not understand any part.

I will follow and obey all local, state and U.S. federal statutes, laws and Program Rules
Janus may terminate my participation if my conduct or actions damage the J-1 Program
I will honor my Job and Work and Travel Program Agreements, policies and terms
If Janus withdraws my sponsorship, I will leave the U.S. and return home within 10 days
If I remain in the U.S. illegally, I can be arrested, deported and denied future entry
If I stay illegally, I understand that Janus is required by U.S. law to advise the U.S. Govt
I know that my full-time job, overtime, and a part-time job are not guaranteed by Janus
I will cooperate with reasonable requests to change any inappropriate behavior
Janus will be contacted by me if I have any problems or concerns during my U.S. stay
For housing that has been arranged for me, I agree to monthly payments for at least 2 months
If I violate housing rules and am evicted, I am still obligated for full 2 months payment
If I cannot complete the W&T Program, for any reason, I must return to my country
I will advise Janus of my arrival date and departure date from the U.S.
My J-1 Visa cannot be converted or changed to another Visa type during my U.S. visit
My Visa will be invalidated if I transfer from one Work and Travel Program to another
It is likely that I will not earn enough $ in the U.S. to cover all of my program expenses
It is my responsibility to ask questions on any terms or details that I do not understand
I will arrange for someone to interpret this application for me if I cannot comprehend it
I will bring enough $ with me to cover 2-4 weeks of food, housing and transportation
I understand that my attendance at the Orientation Session is required for participation
The Health Insurance included in my fees covers the arrival /departure dates indicated
If I decide to extend my stay to the J-1 maximum, I need to advise Janus immediately
I will need additional Health Insurance coverage for any extension of my stay
Janus Health insurance does not cover any pre-existing health conditions from my past
I have written down the phone numbers I need to call in case of emergency
In a health or other emergency, I grant Janus the authority to act as my legal guardian
I understand and authorize any necessary medical treatments not covered by insurance
I grant Janus the authority to act on my behalf and without any liability if I am arrested
To maintain my employment status, I accept the right of Janus to change my location
If my actions result in my program cancellation, I will not be entitled to a refund of fees
I am aware that the legal age for drinking alcohol in the U.S. is 21
I am aware that it is illegal for anyone to provide alcoholic drinks to those under age 21
It is unsafe for you to accept rides, gifts, housing, etc from people you do not know
It is unwise to assume that other people will have your best interests and safety in mind
I am aware that Janus International is not responsible for flight ticket changes in case I need to
transfer to another location or if my job gets cancelled.

By accepting participation in this Work and Travel Program, organized and directed by Janus International
Hospitality Student Exchange LLC, also referred to as Janus, you agree to indemnify and hold Janus, its
employees, directors, officers, agents, coordinators, job sites and support staff, harmless from any claim of
liability for injury, damage, sickness, accident, delay including any expenses incurred by Janus, its
employees, directors, officers, agents, coordinators, job sites and support staff, as it relates to your
employment, that may arise due to strikes, economic conditions, war, quarantine, government restrictions,
or regulations.
UYANGA
________________________________
_________________________________ ________________
Participant Name (print)
Participant Signature
Date