Application For Washington State J-1 Physician Visa Waiver Program Page 9
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Note: The reporting form is available from the department. The physician retention forms must be completed by
the 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 physician does not submit the required retention forms the
department will find the physician is in non-compliance and may notify U.S. Department of State and USCIS.
Non-compliance may jeopardize the physician’s visa status.
21. Does the applicant agree to cooperate in providing the department with clarifying information or
information to verify the contents of this application or any investigation of the applicant’s financial status?
☐Yes ☐No
Note: The applicant will be notified by the department if additional information or assistance is needed.
I hereby acknowledge that all information and statements contained herein are true and do not misrepresent fact. I
further acknowledge that I have not evaded or suppressed any information contained in this application or in any
of the supporting materials.
Applicant
Signature
Date
Physician
Signature
Date
DOH 346-003 September 2016
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