Application Form for Visa Waiver/Change of Status

 

 

Embassy of Nepal 2131 Leroy Place, N. W.
Washington, D. C. 20008

 

Dear Sir/Madame,

I, the undersigned, apply for visa waiver with the following details. I request you to issue a letter to the United States Department of State for the waiver of visa status with regards to the J1visa issued to me by the US Embassy in Nepal. I have enclosed copies of form IAP- 66, my passport, US visa and a copy of my job termination letter/notice (if applicable). Also enclosed is a money order/cashier’s check of US $ 25.00 as processing fee.

1. Applicant’s full name:

2. Address in Nepal:

3. Date and Place of Birth:

4. Passport no. and type:

5. Date of arrival in the United States:

6. Purpose of visit:

7. To be filled by GN/Institutional employees only:

a) Name and address of employer:

b) Date of entry: Date of termination:

8. Cause of termination Resignation Discharge

9. Approximate expenses born by employer for you:

10. Reasons for status change in your existing visa:

11. Case File No. for Visa Waiver:

12. Enclosure of relevant documents, if any:

13. Please also read the following and sign:

I had never before been an employee of Government of Nepal or any other Government-owned organization. Therefore, neither Government nor any other organization did pay the cost of my visit fully or partially. The above statement is true to the best of my knowledge and I will be fully responsible for any consequences that may result in case the above statement is proved false.

Applicant’s signature: ………………………………

Full name:……………….………………………

Address in United States: ………….…………………………………

Apt. no. …………….

City: ………….……..

State: …………………

Zip Code: ……………

Tel:……………………

Date:…………………

 

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