Name and Title of contact person authorized to hire employees
Number & Street
Name of Student to be hired
Job Title & Description
Qualifications, Requirements, English Level
Job Start Date
Job End Date
Are these dates flexible?
Rate per Hour / Salary
Training period rate
Approximate Hours per Week
Is Overtime Available? What rate?
Frequency of Pay (weekly / biweekly)
Deductions from pay (uniforms, etc.)
Will paychecks be issued before the Social Security number is received?
Are 2nd jobs available in your area and will the student be allowed to work a 2nd job?
Is internet access available? Where?
Transportation to and from work (please describe / explain):
Are any meals or meal discounts provided?
Is housing provided or assistance in locating housing?
Housing Cost per Month?
Is housing shared? How many per bedroom?
Type of Accommodation and furnishings
Note: The DS-2019 form cannot be issued without housing arrangements.
Note: Per 26CFR31.6011(b)-2, workers can legally work and receive pay as soon as they apply for the Social Security card.
How long until the 1st paycheck is received?
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Hours per Week
Rate per Hour
Approx. Income (before taxes)
Tax Rate (* 12 - 15%)
Approx. Income (after taxes)
Per Month or Week
# Mos or Wks
Transportation to Work (*$200)
Food (*$10 per day)
House Wares (*$40)
Entertainment / Travel (*$600)
Program Fee with Insurance
Placement Fee (if applicable)
Overseas Agent Fee
Approx. Income after Expenses
Students Printed Name
Student's Legal Signature
Summer Work/Travel Employment Agreement
Company Contact's Legal Signature
I understand the job offer and agree to the conditions described above. I understand and agree to the following: 1) I will participate in all orientation and preparation programs sponsored by the host company; 2) I will comply with all government, company, and sponsor policies, regulations, and laws; 3) infractions, misconduct, or illegal acts may lead to dismissal from the Program; 4)
I MUST report to the host company approved by my Sponsor and listed on my DS-2019 and I am obligated to remain with this host company throughout my entire Work/Travel program;
5) if I have problems with my host company, I understand that I should contact my Sponsor for assistance; 6) if I leave the host company listed on my DS-2019 without my Sponsorís approval, I am subject to termination from the program; 7) if my program is terminated, I will have to return to my home country immediately at my own expense; 8) I am allowed to work a 2nd job if I choose, as long as it does not interfere with my schedule, duties, and obligations at my host company; 9) I am not guaranteed a 2nd job and I am responsible for finding my own 2nd job; 10) some areas of the U.S. are remote and do not have opportunities for 2nd jobs; 11) my host company is not obligated to change my schedule to accommodate a 2nd job; 12) some expenses may not be accounted for in the Budget Sheet calculations but I am still responsible for all of my own expenses; 13)
if this agreement cannot be verified within 3 phone calls, the Sponsor must reject the offer and I will be responsible for submitting a verifiable job offer.
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I will accept the student below as an employee for the dates and conditions listed above. I further understand and agree to the following: 1) the student is only eligible to work during the dates listed on the DS-2019; 2) the student is expected to return to classes in his/her home country at the conclusion of the Program; 3) the Program is not a way for the student to immigrate or change visa status; 4) the student will receive compensation commensurate with that offered to his/her American counterparts; 5) if there is a problem between the student and the host company or if the host company must release the student because of downturn in business or any other unforeseen difficulty, the Sponsor will be notified immediately; 6) the host company will not replace the student prior to arrival if the original job offer dates have not lapsed, even if other students arrive earlier and are available to work sooner; 7) travel plans and arrangements should be worked out directly between the host company and the student and that the Sponsor does not control the studentís travel arrangements; 8) the student must apply for the J-1 visa at the U.S. Consulate in his/her home country and there is no guarantee the visa will be approved; 9) the Summer Work/Travel Program is strictly regulated by the U.S. Department of State and the host company will abide by these regulations; 10) Sponsors must know where each participant is at all times and the host company will cooperate with the Sponsor in all efforts to monitor this studentís program; 11) if the student leaves the host company, the host company will notify the Sponsor within three days; 12) this job offer is valid and I, the undersigned, have the authority to make hiring decisions at this company 13) the student must be paid directly by the host company and the use of staffing agencies is prohibited; 14) even if a placement agency was used to arrange this job, the Sponsor must verify the job directly with the host company; 15)
someone from the Sponsoring Organization will be calling to verify this agreement and I should return the call promptly to expedite the process;
The student will not be issued the DS-2019 until this agreement has been confirmed directly with the host company. Three attempts will be made to verify this agreement.
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