Oklahoma J-1 Visa Waiver Applications 2024-2025

Oklahoma J-1 Visa Waiver Applications 2024-2025

What are you submitting today?

Whole Application

Letter of Intent or Contract

Department of State Case #*

Be Aware

If you are submitting a letter of intention please be advised that you have 3 weeks from the submission of this form to submit the whole application.

You will recieve an update request every week untill the due date at which point the application will be denied.

Please fill out the First Name, Last Name, and Title of the person submitting the request to OSDH for the J-1 Waiver (EX: Bob Jones, JD)*

What is your email address, to which you can be reliably reached?*

Attention

When entering the HPSA IDs, use https://data.hrsa.gov/tools/shortage-area/by-address to enter the facility's address. HPSAs in Proposed for Withdrawal Status are considered if there is not a Designated HPSA.

Enter the HPSA ID of the Designated, Primary Care HPSA. If there is not one, enter the HPSA ID of the Proposed for Withdrawal Primary Care HPSA.

Physician's Date of Birth*

Physician Full Name (As appears on DOS Form 3035)*

What is the Physician's preferred title and name? (EX: Dr. Jones)*

Physician Specialty*

What is the Physician's Last Country of Residence?*

What is the Physician's Country of Birth?*

Starting with the facility that the Physician dedicates and/or will dedicate most of their time to, what is the Facility or Employer Name?*

First Facility Address 1*

First Facility Address 2

First Facility City*

First Facility State*

First Facility Zip Code*

First Facility County*

First Facility HPSA ID (https://data.hrsa.gov/tools/shortage-area/by-address)*

How many more facilities do you need to add?

This will populate additional facility fields to fill out

Select or enter value

Second Facility or Employer Name

Second Facility Address 1

Second Facility Address 2

Second Facility City

Second Facility State

Second Facility Zip Code

Second Facility County

Second Facility HPSA ID (https://data.hrsa.gov/tools/shortage-area/by-address)

Third Facility or Employer Name

Third Facility Address 1

Third Facility Address 2

Third Facility City

Third Facility State

Third Facility Zip Code

Third Facility County

Third Facility HPSA ID (https://data.hrsa.gov/tools/shortage-area/by-address)

Fourth Facility Name or Employer Name

Fourth Facility Address

Fourth Facility City

Fourth Facility State

Fourth Facility Zipcode

Fourth Facility County

Fourth HPSA ID (https://data.hrsa.gov/tools/shortage-area/by-address)

Fifth Facility Name or Employer Name

Fifth Facility Address

Fifth Facility City

Fifth Facility State

Fifth Facility Zipcode

Fifth Facility County

Fifth HPSA ID (https://data.hrsa.gov/tools/shortage-area/by-address)

Six Facility Name or Employer Name

Six Facility Address

Six Facility City

Six Facility State

Six Facility Zipcode

Six Facility County

Six HPSA ID (https://data.hrsa.gov/tools/shortage-area/by-address)

Seventh Facility Name or Employer Name

Seventh Facility Address

Seventh Facility City

Seventh Facility State

Seventh Facility Zipcode

Seventh Facility County

Seventh HPSA ID (https://data.hrsa.gov/tools/shortage-area/by-address)

Eight Facility Name or Employer Name

Eighth Facility Address

Eighth Facility City

Eighth Facility State

Eighth Facility County

Eighth Facility Zipcode

Eight HPSA ID (https://data.hrsa.gov/tools/shortage-area/by-address)

Please upload the application package*

For reference, the application package is located at https://oklahoma.gov/content/dam/ok/en/health/health2/aem-documents/organization/center-for-health-innovation-and-effectiveness/J12021-22%20pkg.pdf

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