WAIVER REVIEW APPLICATION
                                        DATA SHEET

TYPE OR PRINT YOUR ANSWERS IN THE SPACE PROVIDED.
1.  ___________        __________________________________________________________
    MR./MS./DR.                                 SURNAME

2.  ____________________________________     ____________________________________
                FIRST NAME                                MIDDLE NAME
                   ______  ________  _________   ________________________________ 
3. DATE OF BIRTH:   DAY     MONTH      YEAR      PLACE OF BIRTH (CITY AND COUNTRY)

4. NATIONALITY OR LAST LEGAL PERMANENT RESIDENCE AS SHOWN ON IAP-66 FORM
   ______________________________________________________________________________
   
5. DATE & PLACE OF FIRST ENTRANCE TO U.S. ON ORIGINAL EXCHANGE VISITOR (J-1) VISA  
   _______  ___________  _________         ______________________________________
     DAY      MONTH        YEAR                         PORT OF ENTRY

6. PRESENT ADDRESS:
   ______________________________________  7. HOME PHONE: (     )________________
   ______________________________________     BUSINESS PHONE: (     )____________
   ______________________________________

8. LAST U.S. ADDRESS (IF NOT CURRENTLY LIVING IN U.S.)
   _____________________________________________________
   _____________________________________________________
   _____________________________________________________

   FAX NUMBER: (     ) _________________________________     
   E-MAIL: _____________________________________________   
      
9. LIST ALL EXCHANGE VISITOR PROGRAMS IN WHICH YOU PARTICIPATED BEGINNING WITH THE 
   FIRST PROGRAM. (CONTINUE ON SEPARATE SHEET IF NECESSARY)
 
    PROGRAM NUMBER       FIELD CODE NUMBER                 FIELD/SPECIALIZATION
  ___________________   ____________________    __________________________________________
  ___________________   ____________________    __________________________________________
                       
10. GIVE AN EXPLANATION FOR ANY PERIOD OF TIME IN THE U.S. NOT COVERED BY YOUR 
    IAP-66 FORMS. (CONTINUE ON SEPARATE SHEET IF NECESSARY)



11. INS ALIEN REGISTRATION NUMBER:  A ___ ___ - ___ ___ ___ - ___ ___ ___
                                        (IF UNKNOWN, WRITE "UNKNOWN")

12. DID YOUR EXCHANGE VISITOR PROGRAM INCLUDE U.S. GOVERNMENT FUNDS, FUNDS FROM 
    YOUR OWN GOVERNMENT, OR FUNDS FROM AN INTERNATIONAL ORGANIZATION?  
                                                  YES   /   NO    
    (IF YES, PLEASE ATTACH FULL PARTICULARS CONCERNING THE FUNDING ON A SEPARATE 
     SHEET OF PAPER.)

13. DOES THIS APPLICATION INCLUDE J-2 DEPENDENTS?  YES  /   NO  
    (IF YES, PLEASE LIST THEIR FULL NAMES ON A SEPARATE SHEET OF PAPER.)

14. IS YOUR SPOUSE IN J-1 STATUS?  YES  /   NO
    IF YES, IS HE/SHE ALSO APPLYING FOR A WAIVER?    YES  /   NO  
    (IF YES, PLEASE GIVE DETAILS ON A SEPARATE SHEET OF PAPER)

    ____________________________                              ________________
            SIGNATURE                                               DATE





                              APPLICATION INSTRUCTIONS


                                    ATTACHMENTS


      (Remember to keep a copy of any documents sent to us for your own records)

1. PLEASE ATTACH A STATEMENT REGARDING YOUR REASONS FOR NOT WISHING TO FULFILL THE 
   TWO-YEAR COUNTRY RESIDENCE REQUIREMENT TO WHICH YOU AGREED AT THE TIME YOU 
   ACCEPTED EXCHANGE VISITOR STATUS.

2. PLEASE ATTACH COPIES OF ALL IAP-66 FORMS.

3. PLEASE ATTACH PHOTOCOPIES OF ANY I-94 CARDS (FRONT AND BACK).

PLEASE DO NOT STAPLE ANY DOCUMENTS.
PLEASE AVOID TWO-SIDED DOCUMENTS AND USE ONLY 8-1/2" X 11" PAPER.








PLEASE PRINT THE FULL NAME AND ADDRESS WHERE YOU WANT US TO SEND THE 
RECOMMENDATION REGARDING YOUR WAIVER APPLICATION IN UPPERCASE LETTERS IN THE SPACE 
ABOVE.  YOU MUST ALSO INCLUDE A SELF-ADDRESSED STAMPED ENVELOPE.



                                 FEE INFORMATION


PLEASE SEND YOUR APPLICATION, SUPPORTING DOCUMENTS, AND FEE PAYMENT TO:

CA/VO/L/W, VISA SERVICES
U.S DEPARTMENT OF STATE
2401 E STREET, N.W. (SA-1)
WASHINGTON, D.C. 20522-0106

THE APPLICATION FEE IS $136 PER J-1 APPLICANT.  PLEASE SEND A CASHIER'S CHECK OR 
MONEY ORDER IN U.S. CURRENCY DRAWN ON A U.S. BANK, MADE PAYABLE TO THE 
DEPARTMENT OF STATE.  INCLUDE YOUR NAME, DATE AND PLACE OF BIRTH ON WHATEVER FORM 
OF PAYMENT YOU SUBMIT.
 
DO NOT SUBMIT MORE THAN ONE APPLICATION FEE PER PERSON.

WE WILL CONTACT YOU REGARDING THE NEXT STEP IN PROCESSING YOUR APPLICATION.  YOU 
SHOULD RECEIVE A REPLY AND INFORMATION PACKAGE WITHIN 6 WEEKS OF SUBMITTING YOUR 
DATA SHEET AND FEE.

DO NOT CALL TO VERIFY THAT THE APPLICATION HAS ARRIVED.