Application For Washington State J-1 Physician Visa Waiver Program Page 6
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10. Is the Physician complete with residency or fellowship training? ☐ Yes ☐ No
If no, provide the date physician will complete training:
Documentation Required: Submit a letter from the physician’s residency or fellowship program that identifies
the date the physician will complete their residency or fellowship program and confirms that the physician is in
good standing with the program. The letter must be on the program’s letterhead and provide contact information
for the signatory; including name, title, relationship to the physician, address, and telephone number. If physician
has completed the program please submit a copy of the graduate medical education diploma in place of a letter.
11. Did you actively recruit for a U.S. citizen or permanent resident physician candidate for at least six
months before signing a contract with the J-1 physician? ☐ Yes ☐ No
Documentation Required: Provide the information requested below about the recruitment process for a U.S.
candidate undertaken before the organization contracted with the J-1 physician. Please include with this
application an example recruitment document to support the information below. This example document could be
a listing in a national publication, web-based advertising or search agreement with a recruiter or recruitment firm.
Active recruitment period:
Date contract signed with J-1 visa waiver physician:
Recruitment efforts
(Complete sections that apply, leave blank methods not used in the candidate search)
Online advertisements
Time period posted
(e.g. 12/15/2016-08/15/2016)
National publication advertisements
Months published
(e.g. January, March 2016)
Contractual agreement with recruiter or recruitment firm (name of entity)
Date firm began search
Please describe any recruitment efforts in addition to those listed above, attach additional sheet if needed:
12. Do you have a signed employment contract with the physician that includes all the information
described below? ☐Yes ☐No
Documentation Required: Provide two copies of the contract as directed by the instructions of this application.
The contract must contain all the information and conditions outlined below:
Name and address of the applicant who will be employing the physician
Name and street address of the physician’s proposed practice location(s)
Statement of the specific HPSA(s) that will be served by the physician for the duration of the contract
DOH 346-003 September 2016
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