Fillable Ds-7002, 2013, Training/internship Placement Plan printable pdf download

*OMB APPROVAL NO. 1405-0170

U.S. Department of State

EXPIRATION DATE: 12-31-2014

ESTIMATED BURDEN: 1.5 hours

TRAINING/INTERNSHIP PLACEMENT PLAN

SECTION 1: PARTICIPANT INFORMATION

Trainee/Intern Name (Family Name, First Name, Middle Name)

E-mail Address

Select One:

Current Field of Study or Profession

If Professional, Number of Years Experience in Field

(Click Here)

Type of Degree or Certificate

Date Awarded (mm-dd-yyyy) or Expected

Training/Internship Dates (mm-dd-yyyy)

From

SECTION 2: SITE OF ACTIVITY INFORMATION

Name of Supervisor (Last, First, MI)

Title

E-mail Address

Telephone Number

Host Organization Name

Street Address of Training/Internship Site

Suite

City

State

ZIP Code

Website

Employer ID Number (EIN)

Hours Per Week

Will Trainee/Intern receive a stipend?

Yes

No If Yes, how much?

per

Does your organization have a Worker's Compensation (WC) policy?

Will your WC Policy cover the intern/trainee?

Yes

No If so, Name of Carrier

Yes

Number of Full-Time Employees

Annual Revenue

$0 to $3 Million

$3 Million to $10 Million

$10 Million to $25 Million

$25 Million or More

SECTION 3: CONTRACT AGREEMENT

Trainee/Intern - I certify the following:

1. I hereby acknowledge that I have reviewed, understand, and will follow this Training/Internship Placement Plan (T/IPP);

2. That I am entering into this Exchange Visitor Program in order to participate as a Trainee or Intern as delineated in the T/IPP, and not to simply

engage in labor or work in the United States.

3. That I will contact the U.S. Department of State's Bureau of Educational and Cultural Affairs (ECA) at the earliest possible opportunity if I believe

that my Sponsor or Supervisor is not providing me with a legitimate internship or training, as delineated on my T/IPP.

4. I understand that any attempt to falsify, conceal, or cover up by any trick, scheme, or device a material fact by making any materially false,

fictitious, or fraudulent statement or representation; or making or using any false writing or document, knowing the same to contain any materially

false, fictitious, or fraudulent statement or entry is punishable by fine or imprisonment of up to 5 years under Title 18 U.S.C. § 1001.

Signature of Trainee/Intern

Printed Name of Trainee/Intern

Date (mm-dd-yyyy)

Supervisor - I certify the following:

1. I hereby acknowledge that I have reviewed, understand, and will follow this Training/Internship Placement Plan (T/IPP).

2. I will adhere to all applicable regulatory provisions that govern this program (22 CFR Part 62).

3. That Trainees and Interns will not displace full- or part-time, seasonal or permanent American workers, or serve to fill a labor need.

4. I will conduct the required periodic evaluations of this trainee/intern.

5. I will notify the designated Sponsor contact regarding any concerns about, changes in, or deviations from the T/IPP at the earliest available

opportunity, to include, but not limited to, changes of Supervisor or Host Organization, or changes in rotational assignments.

6. I will notify the Sponsor in the event of an emergency involving a Trainee or Intern, as well as any information that I receive about the Trainee or

Intern that might represent a possible threat to their safety, security, welfare, or general well-being.

7. I will notify the Sponsor in the event I receive any information regarding the Trainee or Intern that might be a cause of embarrassment or disgrace

to the Department of State or the Exchange Visitor Program, to include, but not limited to, arrest, or engagement in illegal or immoral activities.

8. That I am participating in this Exchange Visitor Program in order to provide the above listed individual with training or an internship as delineated in

the T/IPP, and not to simply to engage this individual in labor.

9. I understand that any on-the-job training or internship that the Trainee or Intern participates in meets all of the requirements of the Fair Labor

Standards Act, as amended (29 U.S.C. § 201 et seq.).

DS-7002

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