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TRAINING/INTERNSHIP PLACEMENT PLAN

Experience in Field (number of years)Program CategoryTrainee/Intern - I certify that: Annual RevenueTRAINING/ internship PLACEMENT PLANT rainee/Intern Name (Surname/Primary, Given Name(s) (must match passport name)SECTION 1: ADDITIONAL EXCHANGE VISITOR INFORMATIONE-mail Department of StateOccupational CategoryCurrent Field of Study/ProfessionType of Degree or CertificateDate Awarded (mm-dd-yyyy) or ExpectedTraining/ internship Dates (mm-dd-yyyy)FromToSECTION 2: HOST ORGANIZATION INFORMATIONO rganization NamePhase Site Address SuiteCityStateZIP CodeWebsite URLE mployer ID Number (EIN)Exchange Visitor Hours Per WeekCompensationYesNoIf yes, how much?per*OMB APPROVAL NO. 1405-0170 EXPIRATION DATE: 05-31-2024 ESTIMATED BURDEN: hoursWorkers' Compensation PolicyYesNoIf yes, Name of CarrierDoes your Workers' Compensation policy cover exchange visitors ?)

SECTION 1: ADDITIONAL EXCHANGE VISITOR INFORMATION E-mail Address U.S. Department of State Occupational Category Current Field of Study/Profession Type of Degree or Certificate Date Awarded (mm-dd-yyyy) or Expected Training/Internship Dates (mm-dd-yyyy) From To SECTION 2: HOST ORGANIZATION INFORMATION Organization Name Phase Site …

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