Host Company Registration Host Company NameAgency (if any)Address Line 1Address Line 2CityState/ProvinceZIP / Postal CodeEmployer ID NumberNumber of FT Employees Onsite at Location:Annual Revenue:$0-$3 Million$3-$10 Million$10-$25 Million$25 Million or MoreWebsiteWorker's Comp PolicyYesNoIf yes, name of carrierWorker's Comp Policy for Exchange VisitorYesNo, exemptNo, but equivalent coverageWorkers Compensation Insurance Policy ProviderWorkers Compensation Policy NumberWorkers Compensation Policy expiration dateExchange Visitor Hours per WeekStipendYesNoIf yes, how muchNon-Monetary CompensationYesNoIf no, please explainPerson Of ContactFirst Name(can be different from supervisor):Last NameTitleEmail AddressPhoneSupervisorFirst NameLast NameTitleEmail AddressPhoneQualifications of SupervisorHost Company WebsiteParent Company (if any)Parent Company AddressParent Company Employer ID Number (EIN)Please summarize your company’s business activitiesTotal # of full time employees at site of activityTotal # of full time employees company-wideTotal # of J-1 interns or trainees at site of activity including those of other J-1 sponsorsHome OfficeYesNoName of Trainee/InternEmail Address of Trainee/InternTraining/Internship Start DateTraining/Internship End DateTraining/Internship Field:Briefly describe the different phases of the training/internshipState at least 5 internship/training tasks Upload Documents: Workers Compensation Certificate Any Other Documents Upload fileDrag and Drop (or) Choose FilesConsentI have scheduled the Mandatory Supervisor Interview.Submit
