J-1 Visa Waiver Affidavit and Agreement
I, ___________________________________, being duly sworn, hereby request the Federal Co-Chair of the Appalachian Regional Commission to review my application for the purpose of recommending waiver of the foreign residency requirement set forth in my J-1 Visa, pursuant to the terms and conditions as follows:
- I understand and acknowledge that the review of this request is discretionary and that in the event a decision is made not to grant my request, I hold harmless the Appalachian Regional Commission (ARC), the Federal Co-Chair, any and all ARC employees, agents and assigns from any action or lack of action made in connection with this request.
- I further understand and acknowledge that the entire basis for the consideration of my request is the ARC Federal Co-Chair's voluntary policy and desire to improve the availability of primary medical care in regions designated by the United States Public Health Service (USPHS) as Health Professions Shortage Areas (HPSAs) in Appalachia.
- I understand and agree that in consideration for a waiver, which eventually may or may not be granted, I shall render primary medical care services to patients, including the indigent, for a minimum of forty (40) hours per week within a USPHS designated HPSA located in the ARC jurisdiction. Such service shall commence not later than 90 days after I receive approval by the United States Citizenship and Immigration Services (USCIS) of my waiver request and shall continue for a minimum of three (3) years or longer, as a specific State policy may require. Any subsequent change in location must be reported immediately to ARC for concurrence.
- I agree to incorporate all the terms of this J-1 Visa Waiver Affidavit and Agreement into any and all employment agreements I enter pursuant to paragraph 3 and to include in each such agreement the ARC liquidated damages clause, of $250,000 payable to the employer. (A copy of all employment agreements are attached to this request) This damages clause shall be activated by my termination of employment, initiated by my employer for cause or by me for any reason, only if my termination occurs before fulfilling the minimum three year service requirement.
- I further agree that any employment agreement I enter pursuant to paragraph 3 shall not contain any provision, which modifies or amends any of the terms of this J-1 Visa Waiver Affidavit and Agreement.
- I also agree to incorporate all terms of this J-1 Visa Waiver Affidavit and Agreement into any employment agreement I enter pursuant to paragraph 3.
- I understand and agree that I will provide health services to individuals without discriminating against them because (a) they are unable to pay for those services or (b) payment for those health services will be made under Medicare or Medicaid.
- I have read and fully understand the "ARC Federal Co-Chair's J-1 Visa Waiver Policy", a copy of which is attached to this request.
- I expressly understand that this waiver of my foreign residence requirement must ultimately be approved by the USCIS, and I agree to provide written notification of the specific location and nature of my practice to the ARC and the State contact at the time I receive notification from USCIS and I commence rendering services in the ARC jurisdiction.
- I declare and certify, under penalty of the provisions of 18 U.S.C. 1001, that I do not have pending nor am I submitting during the pendency of this request, another request to any United States Government department or agency or any State Department of Public Health, or equivalent, other than the Appalachian Regional Commission to act on my behalf in any matter relating to a waiver of my two-year home-country physical presence requirement.
- I understand and acknowledge that if I willfully fail to comply with the terms of this J-1 Visa Waiver Affidavit and Agreement, the Office of the ARC Federal Co-Chair will notify the USCIS and recommend deportation proceedings be instituted against me. Additionally, any and all other measures available to the Office of the ARC Federal Co-Chair will be taken in the event of my non-compliance.
I declare under the penalties of perjury that the foregoing is true and correct.
Subscribed and sworn before me this _____ day of ________________, 20____.
J-1 Visa Waiver Affidavit and Agreement
PDF format (20 KB)
ARC Federal Co-Chair's J-1 Visa Waiver Policy
J-1 Visa Waivers