Application For Washington State J-1 Physician Visa Waiver Program Page 8
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15. Does the applicant agree to notify the Department of Health in the event of any change in the
physician’s employment status, employment contract or a change in the ownership of the applicant or
practice location if such occurs within the first three years from the state date of physician’s employment?
☐Yes ☐No
Documentation Required: No additional documentation is required to accompany this application. Changes to
the state or federal requirement of the employment contract must be submitted to the department for review and
approval prior to implementation. The department will review and notify applicant of determination within 30
days of receipt of changes. Any changes in employment status may jeopardize the visa status of the physician.
Failure to notify the department of any changes may result in notification of non-compliance to the U.S.
Department of State, U.S. Citizenship and Immigration Services or U.S. Department of Labor as well as
jeopardize the applicant’s future participation in the Washington State J-1 Visa Waiver Program.
16. Does the physician have another application pending with any U.S. government or agency or any other
State Department of Health to act on the physician’s behalf in any matter relating to a waiver of the two-
year home country physical presence requirement? ☐Yes ☐No
Documentation Required: Provide physician statement attesting that no other applications are pending. The
federal government will not allow multiple J-1 visa waiver applications to be submitted simultaneously on behalf
of the same physician.
17. Is the physician contractually obligated to return to a home country? ☐Yes ☐No
Documentation Required: If yes, then the physician must obtain a “No Objection” letter from the physician’s
home country and it must be mailed directly to the U.S. Department of State. Please include a copy with this
application. OR If no, then a signed statement from the physician, indicating that a “No Objection” letter is not
required because the physician is not contractually obligated to return to the home country must be included with
this application.
18. Does the applicant agree to notify the Department of Health, in writing, of the start date of
employment? ☐Yes ☐No
Note: The applicant must notify the department of the employment start date of the physician named in this
application. The start date will be used to determine the due dates for the annual status reports.
19. Do the applicant and physician agree to provide required annual status reports to the department for a
period of three years from the start date of employment? ☐Yes ☐No
Note: The reporting form is available from the department’s Office of Community Health Systems. Employer
report forms must be completed and signed by both the applicant and physician and submitted to the department
within 30 days following the end of each annual period as established by the initial date of employment. If the
applicant does not submit the required employer reports the department will find the applicant is in non-
compliance and may notify U.S. Department of State and USCIS. Non-compliance may jeopardize the
physician’s visa status and the applicant’s future participation in the J-1 Visa Waiver Program.
20. Does the physician agree to provide required annual retention reports to the department for a period of
four years from the start date of employment? ☐Yes ☐No
DOH 346-003 September 2016
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