Form Ds-7002 - Training/internship Placement Plan Template - U.s. Department Of State

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U.S. Department of State

*OMB APPROVAL NO. 1405-0170

EXPIRATION DATE: 07-31-2009

ESTIMATED BURDEN: 60 minutes

TRAINING/INTERNSHIP PLACEMENT PLAN

Check one:

Occupational Field

Number of Years of Experience

Trainee

Level of Degree

Field of Study

Date Awarded (mm-dd-yyyy)

Intern

PARTICIPANT INFORMATION

Trainee/Intern Name (Last, First, MI)

U.S. Residence Address

U.S. Telephone Number

FAX Number

Email Address

SITE OF ACTIVITY INFORMATION

Host Organization

Address

Supervisor's Name (Last, First, MI)

Email Address

Phone Number

Supervisor's Title

FAX Number

Dates of Program (mm-dd-yyyy)

Hours Per Week

Will Trainee/Intern receive a stipend?

If so, how much?

Yes

per

From

CONTRACT AGREEMENT

NOTE- Sponsors will not approve any contracts, and Trainees/Interns may not begin their programs until both a Training/Internship Placement Plan

(page 2) and proof of required insurance that meets 22 CFR 62.14 is on file with the sponsor.

Trainee/Intern- I hereby acknowledge, understand and agree to the attached Training/Internship Placement Plan.

Trainee/Intern Signature

Date (mm-dd-yyyy)

Supervisor- I certify that I will provide on-site supervision and that this training/internship is known and approved by this company/business or

organization (site of activity). I will ensure that the required insurance is in place that meets 22 CFR 62.14 and provide the sponsor with written

evaluations of the trainee/intern's performance, including the number of hours performed, the type of training, and the quality of the performance. At

minimum, I will submit the evaluation at the mid-point and end of the program.

Supervisor's Signature

Date (mm-dd-yyyy)

Sponsor- I approve the attached Training/Internship Placement Plan. I certify the following:

1. Sufficient planning, equipment, and trained personnel will be dedicated to provide the training/internship specified;

2. The training/internship program is not designed to recruit and train aliens for employment in the United States;

3. Trainees/Interns will not displace full-time or part-time U.S. employees; and

4. That training and internship programs in the field of agriculture meet all requirements of the Employment Relationship under the Fair Labor

Standards Act and the Migrant and Seasonal Agricultural Worker Protection Act (29 CFR Part 500).

I understand that false certification may subject me to criminal prosecution under 18 U.S.C. 1001, which reads: "Except as otherwise provided in this

section, whoever, in any matter within the jurisdiction of the executive, legislative, or judicial branch of the Government of the United States, knowingly

and willfully falsifies, conceals, or covers up by any trick, scheme, or device a material fact; makes any materially false, fictitious, or fraudulent

statement or representation; or makes or uses any false writing or document knowing the same to contain any materially false, fictitious, or fraudulent

statement or entry; shall be fined under this title or imprisoned not more than 5 years, or both."

Sponsor's Signature (RO/ARO)

Date (mm-dd-yyyy)

Program Sponsor Name

Program Number

DS-7002

*Public reporting burden for this collection of information is estimated to average 60 minutes per response, including time required for searching existing

Page 1 of 2

data sources, gathering the necessary data, providing the information required, and reviewing the final collection. Persons are not required to provide this

04-2007

information in the absence of a valid OMB approval number. Send comments on the accuracy of this estimate of the burden and recommendations for

reducing it to: U.S. Department of State (A/ISS/DIR) 1800 G St. NW, Washington, DC 20520.