Departure and Return Dates

Arrival date in US: DS-2019 start date: DS-2019 end date: Date of departure from US: 10/12/2013 12/12/2013 15/03/2014 15/03/2014
Can be no more than five days prior to DS start date. Date you want to be eligible to work in the US. Last day you are eligible to work in the US. Can be no more than 4 months after DS start date. Can be no more than 30 days after DS end date and no more then 5 months after arrival date.

Personal Details
Last Name: First Name: Middle Name: Gender: City of Birth: Country of Citizenship: Country of Legal Residence: Passport Number: Passport Expiration Date:

Exactly as they appear on your passport QUISPE VILCAHUAMAN YESENIA JESELY Female JUNIN PERU PERU 5745060 30/07/2017 Permanent Home Address AV. HUANCAVELICA 148 , 01 HUANCAYO 511233057 iezi_123@hotmail.com Postal Code: Country: none PERU Date of Birth (DD/MM/YYYY): 09/11/1994

Contact Information
Home Mailing Address: City: Phone Number: Email:

Alternate Phone: 983481380 Alt. Phone Type:

Emergency Contact
Last Name: First Name: Relationship to Participant: Home Mailing Address: City: Phone Number: Email: VILCAHUAMAN ROJAS SORAYDA MOTHER AV. HUANCAVELICA 148 , 01 HUANCAYO 511233057 iezi_123@hotmail.com Postal Code: Country: none PERU

Alternate Phone: 964104665 Alt. Phone Type:

Previous Visas
Name of Program: Name of Sponsoring Organization: Dates of Previous DS-2019 Form:

Please attach copy of previous visa(s). Yes Program Number: CIEE From: 19/12/2012 City: Vail To: 15/03/2013 State: CO

Have you ever received a J-1 visa to enter the USA?:

Other Visa Information

Have you ever applied for a visa to emigrate permanently to the US?: Have you ever been arrested and convicted of a crime?: Have you ever been refused a visa by a US Embassy?: No No No

*If you answered Yes to any of these questions, please contact your CIEE Representative.

University/College
Name of Institution: City: Major Field of Study: What is the course length of your major field of study (in years)?: How many years of university-level study will you have completed by the time of your departure to the US?: Will you be a full-time university-level student when you return to your country of residence?: 5 2 UNIVERSIDAD CONTINENTAL HUANCAYO

Will you be a full-time university-level student at the time you leave to the US?: Yes Yes

Proof of Student Status

This section must be completed by an official from your educational institution. If your educational institution will not sign this form you must attach an official letter on university letterhead verifying this same information. I certify that the named student is registered in our institution as a full time student for the academic year 2008 is returning to full time studies in the semester following the program. Name of Student: Name of the Official signing the Form: Signature: School Seal/Stamp: Date (DD/MM/YYYY): Title:

English Language Ability

Oral English Abilility: Written English: Listening Comprehension: Advanced Advanced Advanced

Additional comments about the students knowledge of English and his/her ability to function in an English-speaking work place:

Name of Teacher: Name of Educational Institution: Teachers Signature: Date (DD/MM/YYYY):