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Personal Information Personal Details

In this section please answer the questions below in relation to your personal details.

Please select your gender

First Name*

Last Name*

Middle Name

Date Of Birth

Email Address*

Confirm Email*

Mobile Number*

Please drop the 0 from the leading 086 = 86 or 077 = 77

Landline

Address Line 1*

Address Line 2*

Address Line 3

Village\Town\City*

County

Country*

Postal Code

College Name*

Other College

Course Name*

Course Duration (in years)

Registration Date*

Are you in your final year?

Are you an Erasmus Student?

Erasmus Country

Promotion Code

Passport Details

Birth Town*

Please select the country you were born in

Please select the country you are a citizen of

Please select the country you are currently resident within

Passport Number*

Expiry Date

Criminal Convictions

Have you ever been arrested or convicted of a crime in Ireland or abroad?

Please provide details

Next of Kin

Who would you like us to contact in the case of an emergency?

Relationship to you*

First Name*

Surname*

Email*

Telephone*

Booking Information

Have you held a Visa before?

How many times have you been on the J1?

If yes have you ever been terminated on a previous J1 visa?

If yes please describe the reasons why?

Visa Company

Visa Year

Visa Embassy

Insurance Information

For any potential claim that you may submit during / after your J1 in the USA you will be required to submit your private health insurance details. By providing this information at this point will serve to expedite and reduce claims costs in the United States. Please check the Insurance section for more information.

Insurance*

Do you have private medical insurance?

Insurance Company Name

Insurance Policy Type

Insurance Policy Number

Flight Information Outbound Flight

From*

Preferred Destination*

Preferred Departure Date*

You may not arrive in the US earlier than the 15th May

Dietary Requirements

Inbound Flight

Preferred Departure Location*

To*

Preferred Return Date*

Confirm Details » Sayit and Interexchange

J1.ie

Providers of student visas in Ireland.

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