Form I-612 - Application For Waiver Of The Foreign Residence Requirement (Under Section 212(E) Of The Immigration And Nationality Act, As Amended) Page 3

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22.
Country of Last Foreign Residence
Part 3. Reason for Application for Waiver of
Foreign Residence Requirement (continued)
Information About Children
Part 4. Additional Information About You
If you need extra space to complete this section, use the space
If you need extra space to complete this section, use the space
provided in Part 8. Additional Information.
provided in Part 8. Additional Information.
8.a.
Family Name
1.
Provide all exchange program numbers and names or all
(Last Name)
exchange program sponsors.
8.b. Given Name
(First Name)
8.c. Middle Name
9.
Date of Birth (mm/dd/yyyy)
10.
Country of Birth
Major field of activity (Select only one box):
2.a.
Agriculture
Country of Citizenship or Nationality
11.
2.b.
Business Administration
2.c.
Education
12.
Country of Last Foreign Residence
2.d.
Engineering
2.e.
Humanities
2.f.
Medicine
13.a.
Family Name
(Last Name)
2.g.
Natural and Physical Sciences
13.b.
Given Name
2.h.
Social Sciences
(First Name)
13.c.
Middle Name
2.i.
Other
3.
Occupation
14.
Date of Birth (mm/dd/yyyy)
15.
Country of Birth
4.
Date of last entry into the United States as a J-1 participant
in a designated exchange program (mm/dd/yyyy)
16.
Country of Citizenship or Nationality
5.
Port-of-Entry (POE) of last arrival in the United States as
a participant in a designated exchange program
17.
Country of Last Foreign Residence
City or Town
18.a. Family Name
State
(Last Name)
6.
If you are now abroad, provide the date of your most
18.b. Given Name
recent departure from the United States (mm/dd/yyyy)
(First Name)
18.c. Middle Name
19.
Date of Birth (mm/dd/yyyy)
20.
Country of Birth
21.
Country of Citizenship or Nationality
Form I-612 04/24/17 N
Page 3 of 7

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