DEPARTMENT OF HEALTH SERVICES
Division of Public Health
F-43005 (Rev. 10/2018)
S TATE O F WISCONSIN
USDOS, 22 CFR 41.63
APPLICANT PHYSICIAN ASSURANCES
FOR J-1 VI S A WAI VE R APPLICATIONS
Completion of this form satisfies the physician assurances required under U.S. Department of State
regulations, 22 CFR 41.63. Failure to complete this form will result in an application being ineligible for a
state recommendation for a J-1 visa waiver.
The foreign medical physician requesting this J-1 visa waiver recommendation, through the health care
employer identified in the Wisconsin Department of Health Services, Health Care Employer Assurances for
J-1 Visa Waiver Application, F-43006, assures that each of the following statements are factual.
The applicant physician must initial each statement below, and must sign and date at the bottom of
this form.
I agree to the contractual requirements for J-1 visa waiver physicians set forth in
federal immigration law at Public Laws 103-416 and 107-273.
I agree to provide primary care/medical services for the health care employer for a
minimum of 40-hours per week, with at least 32-hours direct patient care, for a period of
three years, and only at the practice address specified in the employment agreement
submitted with this application.
I hereby declare and certify that I do not now have pending nor am I submitting
during the pendency of this request, another request to any United State
Government department or agency or any State Department of Public Health, to act
on my behalf in any matter relating to a waiver of my two-year home-country
physical presence requirement.
I agree to begin working for the health care employer within 90-days of the effective
date of the J-1 visa waiver.
I the applicant physician for whom the health care employer is submitting this
application, do assure that each of these statements is factual.
NOTE: There are federal sanctions for failure to comply with the Immigration and Nationality Act
Requirements. See Wisconsin guidelines For state recommendations for J-1 visa waivers available from the
following Wisconsin Department of Health Services web page:
https://www.dhs.wisconsin.gov/primarycare/j-1visa/index.htm
Print Name of Applicant Physician
SIGNATURE – Applicant Physician
Date Signed
