Application For Washington State J-1 Physician Visa Waiver Program Page 3
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9For DOH Office use only
Date received
Date approved:
Reviewed by:
Application #
Waiver #
Application for Washington State J-1 Physician Visa Waiver Program
U.S. Department of State Case Number:
(This number must be obtained prior to submitting application)
☐ Primary Care Application
☐ HPSA waiver
☐ Specialist Application (also complete Specialist
☐ Non-HPSA waiver (also complete Non-HPSA
Addendum and include with this application)
Addendum and include with this application)
Applicant information
(The employer is the applicant)
Name of applicant:
Mailing address:
City:
State:
Zip:
Contact during application process:
Phone:
Washington State Business License Number (UBI#):
Email:
Contact for reports and issues following waiver approval,
Phone:
if different than above:
Email:
Immigration attorney information
(if applicable)
Name:
Email:
Mailing address:
City:
State:
Zip:
Phone:
J-1 physician information
Name:
Email:
Phone:
Home country:
WA State Medical License #
Date of birth:
Proposed practice location(s) for J-1 physician
(Attach a list of additional practice locations if necessary)
Practice street address:
Zip:
HPSA ID:
City:
State:
Additional address:
Zip:
HPSA ID:
City:
State
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Parent category: Legal