Form 827 E - J-1 Visa Waiver Physician Verification Of Employment

J-1 VISA WAIVER PHYSICIAN VERIFICATION OF EMPLOYMENT FORM

SECTION I

PLEASE CHECK WAIVER PROGRAM:

Conrad State 30

ARC

PHYSICIAN NAME:________________________________________________________________________________________

Please Print

EMPLOYMENT START DATE AT SPONSORING MEDICAL FACILITY: _______________________________________________

INS J-1 Visa Waiver Approval Date: _____________________

H-1B Visa Approval Date: ______________________

PHYSICIAN’S HOME ADDRESS:

_______________________________________________________________________________________________________

Street

City

State

Zip Code:

Email: __________________________________________________________________________________________________

Home Phone: ___________________________________

CELL Phone: _____________________________________

SECTION II

PRACTICE SITE INFORMATION

Name Site 1:

Name Site 2:

Street Address:

City, State, ZIP

Site Phone #:

SECTION III

I HEREBY CERTIFY THAT I, THE UNDERSIGNED, DO PROVIDE PRIMARY HEALTH CARE OR SPECIALITY CARE (IF

APPROVED AS SPECIALIST) AT THE ABOVE STATED SITE(S) A MINIMUM OF 40 HOURS PER WEEK.

_________________________________________________________________

____________________________

Physician's Signature

Date

SECTION IV

THIS SECTION TO BE COMPLETED AND SIGNED BY SPONSORING MEDICAL FACILITY:

I HEREBY CERTIFY THAT DOCTOR_________________________________________________________________________

(Please Check Below As Applicable)

(___) IS WORKING AT SITE(S) LISTED IN SECTION II AND IS IN YEAR _____________ OF SERVICE OBLIGATION

(___) HAS COMPLETED SERVICE OBLIGATION AND STILL AT SITE(S) LISTED IN SECTION II

(___) HAS COMPLETED SERVICE OBLIGATION AND NO LONGER AT SITE(S) LISTED IN SECTION II

(___) DID NOT COMPLETE SERVICE OBLIGATION

(___) TRANSFERRED

(___) WILL START ON ____________________________ AT SITE(S) LISTED IN SECTION II

_________________________________________________________________________

Printed Name of Sponsoring Medical Facility Representative

_______________________________________________________________________

__________________

Signature of Sponsoring Medical Facility Representative

Date

(THIS FORM MUST BE NOTARIZED)

RETURN THIS FORM BY MAIL TO:

Mississippi State Department of Health

ATTN: Director, Office of Rural Health & Primary Care

570 East Woodrow Wilson - P. O. Box 1700

Jackson, Mississippi 39215-1700

Mississippi State Department of Health J-1 Visa Waiver Physician Verification of Employment Form

Form 827 E

01/05/2012

Form 827 E - J-1 Visa Waiver Physician Verification Of Employment - 2012

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