U.S. Department of State
*OMB APPROVAL NO. 1405-0170
EXPIRATION DATE: 07-31-2009
ESTIMATED BURDEN: 60 minutes
TRAINING/INTERNSHIP PLACEMENT PLAN
Number of Years of Experience
Level of Degree
Field of Study
Date Awarded (mm-dd-yyyy)
Trainee/Intern Name (Last, First, MI)
U.S. Residence Address
U.S. Telephone Number
SITE OF ACTIVITY INFORMATION
Supervisor's Name (Last, First, MI)
Dates of Program (mm-dd-yyyy)
Hours Per Week
Will Trainee/Intern receive a stipend?
If so, how much?
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.
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.
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)
Program Sponsor Name
*Public reporting burden for this collection of information is estimated to average 60 minutes per response, including time required for searching existing
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data sources, gathering the necessary data, providing the information required, and reviewing the final collection. Persons are not required to provide this
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.